International Journal of Cancer

Clinical validation of a DNA methylation biomarker associated with overall survival of relapsed ovarian cancer patients

Abstract Approximately 70% of ovarian cancer (OC) patients relapse after chemotherapy, underscoring the need to assess survival before second‐line treatment. We previously identified PLAT‐M8, an 8‐CpG blood‐based methylation signature linked to chemoresistance. This study validates its correlation with clinicopathological features and treatment profiles in additional cohorts. Extracted DNA from whole blood was provided from the BriTROC‐1 ( n  = 47) and OV04 cohorts ( n  = 57) upon the first relapse. Additional samples from Hammersmith Hospital ( n  = 100) were collected during first‐line chemotherapy (Cycles 3–4 and 6). Bisulphite pyrosequencing was used to quantify DNA methylation at the previously identified 8 CpG sites. The methylation data obtained were combined with previous data from ScoTROC‐1D and 1V ( n  = 141) and OCTIPS ( n  = 46). Cox regression was used to assess OS after relapse concerning clinicopathological characteristics. The DNA methylation Class (Class 1 vs. 2) was determined by consensus clustering. As for results, blood DNA methylation at relapse correlates with clinical outcomes, but it has no impact during first‐line treatment. Class 1 is linked to shorter survival (summary OS: HR 2.50, 1.64–3.79) and poorer prognosis on carboplatin monotherapy (OS: aHR 9.69, 95% CI: 2.38–39.47). It is associated with older (>75 years), advanced‐stage, platinum‐resistant patients, residual disease, and shorter PFS. In contrast, Class 2 is linked to platinum sensitivity, higher complete response rates (RECIST), and better prognosis but shows no correlation with CA‐125. These findings highlight PLAT‐M8's potential in guiding second‐line chemotherapy decisions. The PLAT‐M8 methylation biomarker is associated with survival in relapsed OC patients and may potentially predict their response to second‐line platinum treatment.

Classification of high‐grade cervical intraepithelial neoplasia by p16ink4a, Ki‐67, HPV E4 and FAM19A4/miR124‐2 methylation status demonstrates considerable heterogeneity with potential consequences for management

AbstractHigh‐grade cervical intraepithelial neoplasia (CIN2 and CIN3) represents a heterogeneous disease with varying cancer progression risks. Biomarkers indicative for a productive human papillomavirus (HPV) infection (HPV E4) and a transforming HPV infection (p16ink4a, Ki‐67 and host‐cell DNA methylation) could provide guidance for clinical management in women with high‐grade CIN. This study evaluates the cumulative score of immunohistochemical expression of p16ink4a (Scores 0‐3) and Ki‐67 (Scores 0‐3), referred to as the “immunoscore” (IS), in 262 CIN2 and 235 CIN3 lesions derived from five European cohorts in relation to immunohistochemical HPV E4 expression and FAM19A4/miR124‐2 methylation in the corresponding cervical scrape. The immunoscore classification resulted in 30 lesions within IS group 0‐2 (6.0%), 151 lesions within IS group 3‐4 (30.4%) and 316 lesions within IS group 5‐6 (63.6%). E4 expression decreased significantly from CIN2 to CIN3 (P < .001) and with increasing immunoscore group (Ptrend < .001). Methylation positivity increased significantly from CIN2 to CIN3 (P < .001) and with increasing immunoscore group (Ptrend < .001). E4 expression was present in 9.8% of CIN3 (23/235) and in 12.0% of IS group 5‐6 (38/316). Notably, in a minority (43/497, 8.7%) of high‐grade lesions, characteristics of both transforming HPV infection (DNA hypermethylation) and productive HPV infection (E4 expression) were found simultaneously. Next, we stratified all high‐grade CIN lesions, based on the presumed cancer progression risk of the biomarkers used, into biomarker profiles. These biomarker profiles, including immunoscore and methylation status, could help the clinician in the decision for immediate treatment or a “wait and see” policy to reduce overtreatment of high‐grade CIN lesions.

Immunologic impact of chemoradiation in cervical cancer and how immune cell infiltration could lead toward personalized treatment

We investigated the potential of tumor‐infiltrating immune cells (ICs) as predictive or prognostic biomarkers for cervical cancer patients. In total, 38 patients treated with (chemo)radiotherapy and subsequent surgery were included in the current study. This unique treatment schedule makes it possible to analyze IC markers in pretreatment and posttreatment tissue specimens and their changes during treatment. IC markers for T cells (CD3, CD4, CD8 and FoxP3), macrophages (CD68 and CD163) and B cells (CD20), as well as IL33 and PD‐L1, were retrospectively analyzed via immunohistochemistry. Patients were grouped in the low score or high score group based on the amount of positive cells on immunohistochemistry. Correlations to pathological complete response (pCR), cause‐specific survival (CSS) and metastasis development during follow‐up were evaluated. In analysis of pretreatment biopsies, significantly more pCR was seen for patients with CD8 = CD3, CD8 ≥ CD4, positive IL33 tumor cell (TC) scores, IL33 IC < TC and PD‐L1 TC ≥5%. Besides patients with high CD8 scores, also patients with CD8 ≥ CD4, CD163 ≥ CD68 or PD‐L1 IC ≥5% had better CSS. In the analysis of posttreatment specimens, less pCR was observed for patients with high CD8 or CD163 scores. Patients with decreasing CD8 or CD163 scores between pretreatment and posttreatment samples showed more pCR, whereas those with increasing CD8 or decreasing IL33 IC scores showed a worse CSS. Meanwhile, patients with an increasing CD3 score or stable/increasing PD‐L1 IC score showed more metastasis during follow‐up. In this way, the intratumoral IC landscape is a promising tool for prediction of outcome and response to (chemo)radiotherapy.

Boosting the apoptotic response of high‐grade serous ovarian cancers with CCNE1 amplification to paclitaxel in vitro by targeting APC/C and the pro‐survival protein MCL‐1

Ovarian cancer exhibits the highest mortality rate among gynecological malignancies. Antimitotic agents, such as paclitaxel, are frontline drugs for the treatment of ovarian cancer. They inhibit microtubule dynamics and their efficiency relies on a prolonged mitotic arrest and the strong activation of the spindle assembly checkpoint (SAC). Although ovarian cancers respond well to paclitaxel, the clinical efficacy is limited due to an early onset of drug resistance, which may rely on a compromised mitosis exit associated with weakend intrinsic apoptosis. Accordingly, we aimed at overcoming SAC silencing that occurs rapidly during paclitaxel‐induced mitotic arrest. To do this, we used a specific anaphase‐promoting complex/cyclosome (APC/C) inhibitor to prevent a premature mitotic exit upon paclitaxel treatment. Furthermore, we investigated the role of the antiapoptotic BCL‐2 family member MCL‐1 in determining the fate of ovarian cancer cells lines with CCNE1 amplification that are challenged with clinically relevant dose of paclitaxel. Using time‐laps microscopy, we demonstrated that APC/C and MCL‐1 inhibition under paclitaxel prevents mitotic slippage in ovarian cancer cell lines and restores death in mitosis. Consistent with this, the combinatorial treatment reduced the survival of ovarian cancer cells in 2D and 3D cell models. Since a therapeutic ceiling has been reached with taxanes, it is of utmost importance to develop alternative strategies to improve the patient's survival. Thus, our study provides not only elements to understand the causes of taxane resistance in CCNE1‐amplified ovarian cancers but also suggests a new combinatorial strategy that may improve paclitaxel‐based efficacy in this highly lethal gynecological disease.

Multiple lines of chemotherapy for patients with high‐grade ovarian cancer: Predictors for response and effect on survival

AbstractGuidelines for the treatment of tubo‐ovarian cancer patients beyond third line are lacking. We aimed to evaluate the effect of response in each line on patient's outcome as well as identify variables that predict response for additional line of chemotherapy. A cohort study was performed including all patients with advanced high‐grade ovarian cancer. Survival analysis was performed using Kaplan‐Meier curves and log‐rank tests. Odds ratios and hazard ratios were calculated using multilevel, mixed‐effects logistic regression and Cox regression, adjusting for repeated measures within individual patients. Two‐hundred thirty‐eight patients were included and underwent up to 10 lines of chemotherapy. The median progression‐free survival was 15.6 and overall survival (OS) was 55.6 months. Response rates dropped with each additional line and by line 5, most patients (61%) became refractory and only 16% had any type of response (complete 4% or partial 12%). By line 2, whether a patient had partial disease (PR), stable disease (SD) or progressive disease (PD) did not have an effect on the OS. From line 2, whether a patient had PR, SD or PD did not have an effect on chemotherapy‐free interval. Number of previous lines and time from previous line were the only variables that significantly correlated with both outcome of patients and response to the next line. In conclusion, time interval from the previous line of chemotherapy is the major clinical factor that predicts beneficial effect of another line of treatment in patients with ovarian cancer.

The cervical cancer screening program in the North of Portugal: Outcomes after nearly two decades of coexistence with the human papillomavirus vaccine

Abstract As the first vaccinated cohorts are gradually becoming eligible for cervical cancer screening (CCS), changes in the distribution of high‐risk human papillomavirus (hrHPV) infection and associated disease endpoints are expected to occur. We aimed to describe the clinical outcomes of the Regional CCS Program of the North of Portugal in the latest years and to estimate the impact of different hrHPV genotypes on the occurrence of cervical neoplasia. Secondary data collected from the Regional CCS Program of the North of Portugal between January 2019 and December 2024 was used. Descriptive analysis was performed, and the proportion of high‐grade squamous intraepithelial lesion (≥HSIL) attributable to different hrHPV genotypes was estimated. Between January 2022 and December 2024, the prevalence of hrHPV infection was 14.1%, and multiple infections accounted for 28.4% of the cases. Overall, the most prevalent genotypes were HPV‐68 (16.6%), HPV‐52 (14.5%), and HPV‐31 (13.3%). Among the samples that underwent cytological analysis, 14.8% were atypical squamous cells of undetermined significance, 7.2% were low‐grade squamous intraepithelial lesion, and 3.9% were ≥HSIL. Between 2019 and 2024, there was a decrease in the prevalence of the hrHPV genotypes included in the quadrivalent vaccine (17.5%–11.4%), especially in the youngest females, who also experienced a decrease in the frequency of ≥HSIL (6.0%–2.4%). The proportion of ≥HSIL attributable to these hrHPV types decreased from 38.5% to 23.5% in the youngest females, and no significant variations were found for the remaining. This study highlights the considerable reduction of the prevalence of both hrHPV infection and associated cervical abnormalities among the youngest and presumably vaccinated cohorts.

Randomised trial on treatment of vaginal high‐grade squamous intraepithelial lesion: Self‐administered vaginal imiquimod and laser vaporisation

AbstractHigh grade vaginal squamous intraepithelial lesion (HSIL) (or vaginal intraepithelial neoplasia; VAIN) is a rare human papillomavirus (HPV)‐related cancer precursor, which is commonly treated with laser vaporisation or other surgical methods to prevent progression to invasion. Vaginal HSIL has a substantial tendency to relapse despite treatment, for which HPV persistence is a known risk factor. Imiquimod is a topically applied immunomodulator and has shown promise in the treatment of high‐grade HPV‐related genital cancer precursors. The aim of this study was to assess the efficacy and patient compliance of self‐administered vaginal imiquimod in comparison to laser vaporisation in the treatment of vaginal HSIL. We recruited 56 women with histological vaginal HSIL into a randomised controlled trial of laser vaporisation and self‐administered vaginal imiquimod with follow‐up up to 6 months. Follow‐up visits included colposcopy, punch biopsies, and cervical or vaginal swabs for HPV genotyping. In per protocol analyses of 26 women in the laser arm and 27 women in the imiquimod arm, 53.8% and 77.8% (p = 0.07), respectively, showed histological regression at the end of the study. No progressions to invasion were detected during the study period. Genotype‐specific post‐treatment negativity for HPV occurred in 16.7% of the laser group and in 39.1% of the imiquimod group (p = 0.12). Imiquimod had short‐term adverse effects, but 93% completed treatment as instructed. We conclude that vaginal imiquimod is an effective treatment for vaginal HSIL and could be considered an alternative to laser vaporisation.

Outcomes from the English National Lynch Syndrome transformation project

Abstract The English National Health Service (NHS) Lynch Syndrome Transformation Project was established to deliver universal testing for Lynch syndrome (LS) of newly diagnosed colorectal (CRC) and endometrial cancer (EC). A central aim was to integrate ‘mainstreamed’ genetic testing into routine care by cancer multidisciplinary teams in England. In June 2021 national and regional LS project teams were established to support ‘LS champions’ within local cancer multidisciplinary teams (MDTs). A comprehensive retrospective genomic dataset and dashboard was compiled by the National Disease Registration Service (NDRS), complimented with prospective local MDT audit (2022–2023). A robust national registry of people diagnosed with LS was developed to ascertain individuals for targeted interventions, including for a new national LS Bowel Cancer Screening Programme (LS‐BCSP). In total 276 LS champions were appointed and trained across 248 CRC and EC MDTs (>95% coverage nationally). Tumour Mismatch repair (MMR) tumour testing rates increased for CRC (43 >94%) and EC (19 >94%). MDT‐led mainstreaming services were developed in 46% of all CRC and 41% EC teams in England. In subgroup data, the time to germline genetic testing was 21 days in ‘mainstreamed’ patients, versus 180 days referred to regional clinical genetics services. New diagnoses of LS have consistently increased each year from a total of 545 in 2020 to a total of 1394 in 2024 (an increase of 255% vs. a target of >50%). The NHS England LS Transformation project has driven equitable nationwide delivery of diagnosis testing for Lynch syndrome, with integration of ‘mainstreamed’ genetic testing into routine cancer care.

Doppel as an early‐stage biomarker promoting EMT and dissemination in ovarian cancers

Abstract Detecting ovarian cancer (OC) early using existing biomarkers, for example, cancer antigen 125 (CA125), is challenging due to its ubiquitous expression in many tissues. Doppel, a prion‐like protein, expresses in the male reproductive organ but is absent in female reproductive systems and healthy tissues, but plays an important role in neo‐angiogenesis. Here, we have shown two platforms, soluble Doppel in sera/ascites and Doppel expressed in circulating tumor cells ( Dpl+ CTC) in the whole blood, to detect subsets of epithelial OC (EOC). Increased levels of Doppel in the sera of OC patients, in three different cohorts, confirm Doppel as an OC‐specific biomarker. Serum Doppel levels can distinguish OC with high sensitivity and specificity (sensitivity = 0.91 and specificity = 0.89) and can also detect early‐stage HGSOCs (FIGO stages I and II) from non‐cancerous conditions with high sensitivity and specificity (sensitivity = 0.94 and specificity = 0.83). Moreover, significantly higher Doppel expression is observed in all EOC subtypes except clear cell OC. Stratifying the EOCs based on Doppel levels, we categorized them into Doppel‐high (Dpl hi ) and Doppel‐low (Dpl low ) groups. Using ascites‐derived organoids, made from Dpl hi and Dpl low patients, we identify that Doppel induces epithelial–mesenchymal transition (EMT). Doppel levels in the sera/ascites correlate with the changes in Dpl+ CTC number in whole blood, highlighting the association of Doppel‐induced EMT with CTC dissemination in the circulation. Thus, Doppel‐based detection of EOC subtypes could be a promising platform as a clinical biomarker and link the Doppel axis with OC dissemination.

Germline variants observed in pediatric cancer patients related to hereditary breast and ovarian cancer in adults

Abstract Genetic predisposition is a major cause of cancer, yet little is known about the role of adult cancer predisposition syndromes (CPSs) in childhood cancers. Although extensively studied in adults, information about the impact of germline variants in genes associated with hereditary breast and ovarian cancer (HBOC) remains scarce in the pediatric context. To elucidate whether (likely) pathogenic variants (LP/PVs) in 25 selected HBOC‐related genes may contribute to cancer risk in children, we analyzed the spectrum of occurring germline variants. We assessed 372 children (median age at diagnosis 5.1 [0–22.2] years; 160 girls [43%]), including 212 (57%) with hematologic neoplasms, 71 (19%) with brain tumors, and 89 (24%) with various solid entities. Twenty‐seven of 372 patients (7%) carried LP/PVs in the candidate genes; for 12 of 27 (44%) no CPS was suspected prior to genotyping. LP/PV carriers were particularly at risk for second malignancies (SMN; 5/27 vs. 13/345; OR = 5.8; p  = .0021); yet, LP/PVs in SMN‐developing patients resided exclusively in TP53 ( n  = 3), NBN ( n  = 1), and ATM ( n  = 1). Burden testing of our single‐center cohort revealed considerable associations between monoallelic LP/PVs in five HBOC‐related genes ( TP53 , CHEK2 , ATM , NF1 , and NBN ) and pediatric cancers compared to healthy adults (gnomAD v.3.1.1, non‐cancer dataset). Joint analyses adding 1120 individuals from a previous study Zhang et al. (2015) confirmed significant associations for TP53 , CHEK2 , NF1 , and MSH2 . Monoallelic LP/PVs in constrained HBOC‐related genes are significantly associated with pediatric cancers. However, particularly in clinically unexpected cases, detection of contributing LP/PVs by genotype‐driven approaches may improve patient outcomes by enabling risk‐adapted therapy and surveillance.

Limited association between HRR gene alterations and HRD in molecular tumor board cancer samples: Who should be tested for HRD?

AbstractAlterations in Homologous Recombination Repair (HRR) Pathway genes have been found to be associated with HR‐Deficiency (HRD), which is an approved biomarker for PARP Inhibitor (PARPi) treatment. The aim of a Molecular Tumor Board (MTB) is to identify molecular alterations in cancer patients with advanced tumors that may suggest off‐label treatment options. So far, few studies have analyzed the presence of HRR gene mutations and their association with HRD outside of clinical studies. Currently, no data on HRD testing in the setting of a MTB have been published. For the present study, a cohort of 237 patients encompassing 24 different tumor entities was collected from the MTB of the Comprehensive Cancer Center Erlangen‐EMN. We show that an elevated Genomic Instability Score (GIS ≥42) can occur in samples with and without mutations in HRR‐related genes. Overall, 38.1% of cancer samples with BRCA1/2 mutations, 10.9% of tumors with alterations in HRR genes other than BRCA1/2, and 4.3% of cancer samples without HRR gene mutations harbored an elevated GIS. Notably, our data show that various inactivating BRCA1/2 mutations are not associated with an elevated GIS. Taken together, panCancer assessment of HRD in addition to BRCA1/2 and other HRR gene mutational analysis is recommended to guide decisions regarding PARPi treatment. Further studies are needed to establish thresholds for GIS in non‐ovarian cancer entities. Finally, HRD can be observed in 4.3% of BRCA1/2 and other HRR gene wildtype cancer samples, and may emerge as an independent biomarker for PARPi in the future.

The TESTBREAST journey: Revisiting the importance of early detection by frequent screening of women at high risk of breast cancer

AbstractWomen with an inherited pathogenic variant (PV) in a breast cancer (BC) susceptibility gene, or familial predisposition (FP) have an increased risk to develop BC. There is a need for improvement of screening methods due to interval cancers and radiation exposure. The aim of the TESTBREAST study is to develop a blood test suitable for early diagnosis. Here, the clinical composition of participants is provided. From 2010 to 2022, 1108 women were included in the TESTBREAST study, with currently 750 participants suitable for serum analysis.The median follow‐up was 7 years [1–14]. Of the 1108 participants, 70% (n = 728) had a PV. BC was diagnosed in 16.5% (n = 124), mainly stage I‐II (68.5%), and mostly BRCA1 (n = 47, 47%) and BRCA2 (n = 29, 29%) carriers. Invasive cancer was diagnosed in 100 cases: 76% (n = 76) had a PV with a median age of 49 [26–68] at diagnosis, whereas 24% (n = 24) had a FP, with a median age of 51 years [25–65]. The general population (the Netherlands) is aged 61 years on average at diagnosis. Triple negative breast cancer (TNBC) occurred in 51% (n = 39) of the TESTBREAST women with a PV, whereas this was 11% in the general population. Within the TESTBREAST cohort, BRCA carriers were younger at diagnosis and often had the aggressive TNBC subtype. Improvement of current screening methods for early detection is especially important for this group of high‐risk women to reduce interval cancers, exposure to radiation, and to improve survival.

Nationwide implementation and evaluation of the Tumor‐First workflow for genetic testing in ovarian carcinoma

AbstractDespite international agreement on the importance of tumor DNA testing and germline testing for determining PARP inhibitor treatment eligibility in patients with ovarian carcinoma (OC) and for cancer prevention in their relatives, the optimal strategy remains under debate. In the Netherlands, the “Tumor‐First workflow” was initiated and implemented nationwide: a well‐validated tumor DNA test is the primary test for detecting tumor pathogenic variants (PVs) in OC risk genes (BRCA1/2, RAD51C/D, BRIP1, PALB2). The detection of tumor PVs is subsequently used to stratify germline testing and determine treatment eligibility. The Tumor‐First workflow is efficient and saves costs. The aim of this study was to evaluate the nationwide implementation of the Tumor‐First workflow. We analyzed real‐time genetic testing practices, including tumor DNA and germline testing, in patients diagnosed with OC from 2019 to 2023, as identified through the Dutch Pathology Registry (Palga). Testing data were collected from diagnostic pathology and genetic reports. Out of the 3926 OC patients, 2778 (71%) received OC tumor DNA testing as the primary test. Between 2019 and 2023, this percentage increased from 50% to 85%. Of these tumor DNA tests, 2703 (97%) were successful, with 398 (15%) resulting in the identification of a PV in an OC risk gene. Most of these patients (291; 73%) underwent germline testing, and 147 (51%) were found to have a germline PV. We conclude that the nationwide implementation of the Tumor‐First workflow for OC was effective. Multidisciplinary efforts contributed to a more efficient detection of germline and somatic PVs in OC risk genes.

Gene expression markers in peripheral blood and outcome in patients with platinum‐resistant ovarian cancer: A study of the European GANNET53 consortium

AbstractDisease progression is a major problem in ovarian cancer. There are very few treatment options for patients with platinum‐resistant ovarian cancer (PROC), and therefore, these patients have a particularly poor prognosis. The aim of the present study was to identify markers for monitoring the response of 123 PROC patients enrolled in the Phase I/II GANNET53 clinical trial, which evaluated the efficacy of Ganetespib in combination with standard chemotherapy versus standard chemotherapy alone. In total, 474 blood samples were collected, comprising baseline samples taken before the first administration of the study drugs and serial samples taken during treatment until further disease progression (PD). After microfluidic enrichment, 27 gene transcripts were analyzed using quantitative polymerase chain reaction and their utility for disease monitoring was evaluated. At baseline, ERCC1 was associated with an increased risk of PD (hazard ratio [HR] 1.75, 95% confidence interval [CI]: 1.20–2.55; p = 0.005), while baseline CDH1 and ESR1 may have a risk‐reducing effect (CDH1 HR 0.66, 95% CI: 0.46–0.96; p = 0.024; ESR1 HR 0.58, 95% CI: 0.39–0.86; p = 0.002). ERCC1 was observed significantly more often (72.7% vs. 53.9%; p = 0.032) and ESR1 significantly less frequently (59.1% vs. 78.3%; p = 0.018) in blood samples taken at radiologically confirmed PD than at controlled disease. At any time during treatment, ERCC1‐presence and ESR1‐absence were associated with short PFS and with higher odds of PD within 6 months (odds ratio 12.77, 95% CI: 4.08–39.97; p < 0.001). Our study demonstrates the clinical relevance of ESR1 and ERCC1 and may encourage the analysis of liquid biopsy samples for the management of PROC patients.

Germline variants of homology‐directed repair or mismatch repair genes in cervical cancer

AbstractWhile cervical cancer is associated with a persistent human papillomavirus (HPV) infection, the progression to cancer is influenced by genomic risk factors that have remained largely obscure. Pathogenic variants in genes of the homology‐directed repair (HDR) or mismatch repair (MMR) are known to predispose to diverse tumour entities including breast and ovarian cancer (HDR) or colon and endometrial cancer (MMR). We here investigate the spectrum of HDR and MMR germline variants in cervical cancer, with particular focus on the HPV status and histological subgroups. We performed targeted next‐generation sequencing for 5 MMR genes and 12 HDR genes on 728 German patients with cervical dysplasia or invasive cancer. In total, 4% of our patients carried a pathogenic germline variant, based on ClinVar classifications and additional ESM1b and AlphaMissense predictions. These included 15 patients with truncating variants in HDR genes (BARD1, BRCA1, BRCA2, BRIP1, FANCM, RAD51D and SLX4). MMR‐related gene variants were less prevalent and mainly of the missense type. While MMR‐related gene variants tended to associate with adenocarcinomas, HDR gene variants were commonly observed in squamous cancers. While one patient with HPV‐negative cancer carried a pathogenic MMR gene variant (in MSH6), the HDR germline variants were found in patients with HPV‐positive cancers and tended to associate with HPV18. Taken together, our study supports a potentially risk‐modifying role of MMR and HDR germline variants in cervical cancer but no association with HPV‐negative status. These variants may be exploitable in future therapeutic managements.

Curvilinear incidence models for parity in the entire fertility range for cancers of the breast, ovary, and endometrium: A follow‐up of the Norwegian 1960 Census

AbstractThe protective effect of parity has been demonstrated for cancer of the breast, ovary, and endometrium but no studies have estimated the effect of each subsequent birth in women with 10 or more children or grand‐grand parity women, nor compared the linear relationship of the three cancers sites. Here, we aim to explore these relationships based on the Norwegian 1960 Census. The question of parity in present marriage was answered by 385,816 women born 1870–1915, a period with high fertility. Age at marriage has been validated as a proxy for age at first birth AFB. With high parity age at first birth will logically be restricted to early births giving structural zeros. Follow‐up was based on linkages to national registers until the first of any of the three diagnoses, death, or age 90 before 31.12.2005. Included were 16,905 breast cancers, 3827 ovarian cancers, and 3834 endometrial cancers. Age‐ and period‐specific incidence rates based on person‐years, PY, were used in logit regression models. The percentage decrease for each additional child over the total parity range was for breast cancer 10.5% (95% CI; 9.6–11.4), ovarian cancer 13.2% (11.2–15.3), and endometrial cancer 10.9% (8.9–12.8), in a model without higher order terms. Adjustment for structural zeros reduced the effect of age at first birth to less than one additional child. To the best of our knowledge this is the first analysis of the curvilinear relationships for cancers of the breast, ovary, and endometrium throughout the extended fertility range.

Enhancing precision targeting of ovarian cancer tumor cells in vivo through extracellular vesicle engineering

Abstract Extracellular vesicles (EVs) function as natural mediators of intercellular communication, secreted by cells to facilitate cell–cell signaling. Due to their low toxicity, immunogenicity, biodegradability, and potential to encapsulate therapeutic drugs, EVs hold significant therapeutic promise. Nevertheless, their limited targeting ability often diminishes their therapeutic impact. Therefore, enhancing EVs by incorporating targeting units onto their membranes could bolster their targeting capabilities, enabling them to accumulate in specific cells and tissues. In this study, we engineered EVs to fuse ephrin‐B2 with the EV membrane protein LAMP2b. This modification aimed to direct the engineered EVs toward the ephrin‐B4 receptor expressed on the surface of ovarian cancer cells. The engineered EVs retained their inherent properties, including size, expression of EV membrane proteins, and morphology, upon isolation. In vitro experiments using real‐time imaging revealed that EVs engineered with the ephrin‐B2 ligand exhibited substantial internalization and uptake by ovarian cancer cells, in stark contrast to native EVs. In vivo, the engineered EVs carrying the ephrin‐B2 ligand effectively targeted ovarian cancer cells, surpassing the targeting efficiency of control EVs. This innovative approach establishes a novel targeting system, enhancing the uptake of EVs by ovarian cancer cells. Our findings underscore the potential of using EVs to target cancer cells, thereby enhancing the effectiveness of anti‐cancer therapies while minimizing off‐target effects and toxicity in normal cells and organs.

Pelvic inflammatory disease and risk of borderline ovarian tumors: A national population‐based case–control study in Sweden

AbstractThe resemblance between fallopian tube cells and serous borderline ovarian tumors (BOTs) suggests a potential origin link, with salpingitis proposed as a contributing factor in the pathogenesis of BOT. This study aimed to explore the potential association between pelvic inflammatory disease (PID) and the risk of developing BOT. A national population‐based case–control study in Sweden included women with BOT between 1999 and 2020 and 10 matched controls. Data from nationwide registers were analyzed using conditional logistic regression, adjusting for age, residential district, educational level and parity. Among 4782 cases and 45,167 controls, 2.0% of cases and 1.3% of controls had a history of PID. Previous PID was associated with an increased risk of BOT overall (aOR, 1.48; 95% CI, 1.19–1.85). Significant association was observed with serous tumors (aOR, 1.76; 95% CI, 1.36–2.29), while not with mucinous tumors (aOR, 0.95; 95% CI, 0.60–1.49). A dose–response relationship between number of PID episodes and serous BOT risk was noted (Ptrend < .001). This study demonstrates that PID is associated with increased risk of serous BOT, with a dose response relationship. The study highlights the potential serious implications of upper reproductive tract infections and inflammation. This underscores the need for further investigation of biological mechanisms and possible impact of PID on serous BOT development.

Prospective evaluation of 92 protein biomarkers for early detection of endometrial cancer

Abstract The human epididymis protein 4 (HE4) remains the best available endometrial cancer (EC) biomarker; however, its discrimination between cases and cancer‐free individuals is limited and might be improved when combined with other protein markers. We evaluated the discrimination capacity of 92 proteins as potential early detection biomarkers for EC in nested case–control studies in the European Prospective Investigation into Cancer and Nutrition (EPIC) (63 cases, 123 controls) and Janus (75 cases, 146 controls) cohorts, evaluating blood samples taken ≤2 years prior to diagnosis. Proteins were measured with the Olink Target 96 Oncology II panel assays. Areas under the receiver operating characteristic curves (AUCs) were calculated using logistic regression. The discrimination between cases and controls of top‐performing proteins was modest (EPIC: HE4, CA125, CAIX, and S100A4; Janus: HE4, CA125, FURIN, CXCL13, and IL6; AUC range: 0.65 [S100A4], 0.76 [HE4, EPIC] within 0 to <12 months of blood collection) and decreased as the time between blood draw and cancer diagnosis increased (12–24 months AUC range: 0.49 [S100A4], 0.69 [CA125, Janus]). The combination of these other markers with HE4 did not improve discrimination. HE4 and other candidate proteins had limited discrimination between EC cases and controls and hence do not appear to be useful for early detection of this disease in women at average population risk.

B cells critical for outcome in high grade serous ovarian carcinoma

Abstract Recent work has shown evidence for the prognostic significance of tumor infiltrating B cells (B‐TIL) in high grade serous ovarian carcinoma (HGSOC), the predominant histological subtype of ovarian cancer. However, it remains unknown how the favorable prognosis associated with B‐TIL relates to the current standard treatments of primary debulking surgery (PDS) followed by chemotherapy or (neo‐)adjuvant chemotherapy (NACT) combined with interval debulking surgery. To address this, we analyzed the prognostic impact of B‐TIL in relationship to primary treatment and tumor infiltrating T cell status in a highly homogenous cohort of HGSOC patients. This analysis involved a combined approach utilizing histological data and high‐dimensional flow cytometry analysis. Our findings indicate that while HGSOC tumors pre‐treated with NACT are infiltrated with tumor‐reactive CD8 + and CD4 + TIL subsets, only B‐TIL and IgA plasma blasts confer prognostic benefit in terms of overall survival. Importantly, the prognostic value of B‐TIL and IgA plasma blasts was not restricted to patients treated with NACT, but was also evident in patients treated with PDS. Together, our data point to a critical prognostic role for B‐TIL in HGSOC patients independent of T cell status, suggesting that alternative treatment approaches focused on the activation of B cells should be explored for HGSOC.

Performance evaluation of predictive models for detecting MMR gene mutations associated with Lynch syndrome in cancer patients in a Chinese cohort in Taiwan

Abstract Identifying Lynch syndrome significantly impacts cancer risk management, treatment, and prognosis. Validation of mutation risk predictive models for mismatch repair (MMR) genes is crucial for guiding genetic counseling and testing, particularly in the understudied Asian population. We evaluated the performance of four MMR mutation risk predictive models in a Chinese cohort of 604 patients with colorectal cancer (CRC), endometrial cancer (EC), or ovarian cancer (OC) in Taiwan. All patients underwent germline genetic testing and 36 (6.0%) carried a mutation in the MMR genes ( MLH1 , MSH2 , MSH6 , and PMS2 ). All models demonstrated good performance, with area under the receiver operating characteristic curves comparable to Western cohorts: PREMM 5 0.80 (95% confidence interval [CI], 0.73–0.88), MMRPro 0.88 (95% CI, 0.82–0.94), MMRPredict 0.82 (95% CI, 0.74–0.90), and Myriad 0.76 (95% CI, 0.67–0.84). Notably, MMRPro exhibited exceptional performance across all subgroups regardless of family history (FH+ 0.88, FH‐ 0.83), cancer type (CRC 0.84, EC 0.85, OC 1.00), or sex (male 0.83, female 0.90). PREMM 5 and MMRPredict had good accuracy in the FH+ subgroup (0.85 and 0.82, respectively) and in CRC patients (0.76 and 0.82, respectively). Using the ratio of observed and predicted mutation rates, MMRPro and PREMM 5 had good overall fit, while MMRPredict and Myriad overestimated mutation rates. Risk threshold settings in different models led to different positive predictive values. We suggest a lower threshold (5%) for recommending genetic testing when using MMRPro, and a higher threshold (20%) when using PREMM 5 and MMRPredict. Our findings have important implications for personalized mutation risk assessment and counseling on genetic testing.

Role of artificial intelligence applied to ultrasound in gynecology oncology: A systematic review

AbstractThe aim of this paper was to explore the role of artificial intelligence (AI) applied to ultrasound imaging in gynecology oncology. Web of Science, PubMed, and Scopus databases were searched. All studies were imported to RAYYAN QCRI software. The overall quality of the included studies was assessed using QUADAS‐AI tool. Fifty studies were included, of these 37/50 (74.0%) on ovarian masses or ovarian cancer, 5/50 (10.0%) on endometrial cancer, 5/50 (10.0%) on cervical cancer, and 3/50 (6.0%) on other malignancies. Most studies were at high risk of bias for subject selection (i.e., sample size, source, or scanner model were not specified; data were not derived from open‐source datasets; imaging preprocessing was not performed) and index test (AI models was not externally validated) and at low risk of bias for reference standard (i.e., the reference standard correctly classified the target condition) and workflow (i.e., the time between index test and reference standard was reasonable). Most studies presented machine learning models (33/50, 66.0%) for the diagnosis and histopathological correlation of ovarian masses, while others focused on automatic segmentation, reproducibility of radiomics features, improvement of image quality, prediction of therapy resistance, progression‐free survival, and genetic mutation. The current evidence supports the role of AI as a complementary clinical and research tool in diagnosis, patient stratification, and prediction of histopathological correlation in gynecological malignancies. For example, the high performance of AI models to discriminate between benign and malignant ovarian masses or to predict their specific histology can improve the diagnostic accuracy of imaging methods.

Heterogeneous treatment effect of dose‐dense paclitaxel plus carboplatin therapy for advanced ovarian cancer

AbstractA Japanese clinical trial (JGOG3016) showed that dose‐dense weekly paclitaxel in combination with carboplatin extensively prolonged overall survival (OS) in patients with advanced ovarian cancer. However, in other clinical trials, dose‐dense paclitaxel regimens were not superior to triweekly paclitaxel regimens. In this study, causal tree analysis was applied to explore subpopulations with different treatment effects of dose‐dense paclitaxel in a data‐driven approach. The 587 participants with stage II–IV ovarian cancer in the JGOG3016 trial were used for model development. The primary endpoint was treatment effect in terms of 3‐year OS in patients receiving dose‐dense vs. conventional paclitaxel therapies. In patients <50 years, the 3‐year OS was similar in both groups; however, it was higher in the dose‐dense group in patients ≥50 years. Dose‐dense paclitaxel showed strong positive treatment effects in patients ≥50 years with stage II/III disease, BMI <23 kg/m2, non‐CC/MC, and residual tumor ≥1 cm. In contrast, although there was no significant difference in OS; the 3‐year OS rate was 23% lower in dose‐dense paclitaxel than conventional paclitaxel in patients ≥60 years with stage IV cancer. Patients in this group had a particularly lower performance status than other groups. Our causal tree analysis suggested that poor prognosis groups represented by residual tumor tissue ≥1 cm benefit from dose‐dense paclitaxel, whereas elderly patients with advanced disease and low‐performance status are negatively impacted by dose‐dense paclitaxel. These subpopulations will be of interest to future validation studies. Personalized treatments based on clinical features are expected to improve advanced ovarian cancer prognosis.

Loss of copy numbers of retrotransposons (HERVK) on chromosome 7p11.2 impacts EGFR (Epidermal Growth Factor Receptor)‐induced phenotypes for platinum sensitivity and long‐term survival in ovarian cancer—A study from the OVCAD consortium

AbstractWe analyzed variations in the epidermal growth factor receptor (EGFR) gene and 5′‐upstream region to identify potential molecular predictors of treatment response in primary epithelial ovarian cancer. Tumor tissues collected during debulking surgery from the prospective multicenter OVCAD study were investigated. Copy number variations in the human endogenous retrovirus sequence human endogenous retrovirus K9 (HERVK9) and EGFR Exons 7 and 9, as well as repeat length and loss of heterozygosity of polymorphic CA‐SSR I and relative EGFR mRNA expression were determined quantitatively. At least one EGFR variation was observed in 94% of the patients. Among the 30 combinations of variations discovered, enhanced platinum sensitivity (n = 151) was found dominantly with HERVK9 haploidy and Exon 7 tetraploidy, overrepresented among patients with survival ≥120 months (24/29, p = .0212). EGFR overexpression (≥80 percentile) was significantly less likely in the responders (17% vs. 32%, p = .044). Multivariate Cox regression analysis, including age, FIGO stage, and grade, indicated that the patients' subgroup was prognostically significant for CA‐SSR I repeat length <18 CA for both alleles (HR 0.276, 95% confidence interval 0.109–0.655, p = .001). Although EGFR variations occur in ovarian cancer, the mRNA levels remain low compared to other EGFR‐mutated cancers. Notably, the inherited length of the CA‐SSR I repeat, HERVK9 haploidy, and Exon 7 tetraploidy conferred three times higher odds ratio to survive for more than 10 years under therapy. This may add value in guiding therapies if determined during follow‐up in circulating tumor cells or circulating tumor DNA and offers HERVK9 as a potential therapeutic target.

Ovarian cancer survival in sub‐Saharan Africa by human development index and histological subtypes: A population‐based registry study

AbstractOvarian cancer (OC) is the fourth most common cancer of women in sub‐Saharan Africa (SSA), although few data have been published on population‐level survival. We estimate ovarian cancer survival in SSA by human development index and histological subtype, using data from seven population‐based cancer registries in six countries: Kenya (Nairobi and Eldoret), Mauritius, Uganda (Kampala), Cote d'Ivoire (Abidjan), Ethiopia (Addis Ababa) and South Africa (Eastern Cape). A total of 644 cases diagnosed during 2008–2014 were included, with 77% being of epithelial subtypes (range 47% [Abidjan]—80% [Mauritius]). The overall observed survival in the study cohort was 73.4% (95% CI: 69.8, 77.0) at 1 year, 54.4% (95% CI: 50.4, 58.7) at 3 years and 45.0% (95% CI: 41.0, 49.4) at 5 years. Relative survival at Year 1 ranged from 44.4% in Kampala to 86.3% in Mauritius, with a mean for the seven series of 67.4%. Relative survival was highest in Mauritius at 72.2% and lowest in Kampala, Uganda at 19.5%, with a mean of 47.8%. There was no difference in survival by age at diagnosis. Patients from high and medium HDI countries had significantly better survival than those from low HDI countries. Women with cancers of epithelial cell origin had much lower survival compared to women with other histological subtypes (p = .02). Adjusted for the young age of the African patients with ovarian cancer (44% aged <50) survival is much lower than in USA or Europe, and underlines the need for improvements in the access to diagnosis and treatment of OC in SSA.

Revealing genes associated with cervical cancer in distinct immune cells: A comprehensive Mendelian randomization analysis

AbstractHuman papillomavirus can be contracted by sexually active women. However, only a small proportion of these infections persist and have the potential to progress into cervical cancers, indicating a significant involvement of the immune system in cervical cancer development. Despite this, our understanding of the precise contributions of genes from different immune cell types in cervical cancers remains limited. Therefore, the primary objective of our study was to investigate the potential causal relationships between specific immune cell genes and the development of cervical cancers. By accessing expression quantitative trait loci datasets of 14 distinct immune cell types and genome wide association study of cervical cancers, we employed the summary data‐based Mendelian randomization (SMR) along with multi‐single nucleotide polymorphism (SNP)‐based SMR to identify significant genes associated with cervical cancers. Colocalization analysis was further conducted to explore the shared genetic causality. A total of 10 genes across 11 immune cell types (26 significant gene‐trait associations) were found to be associated with cervical cancers after false discovery rate correction. Notably, the ORMDL3, BRK1 and HMGN1 gene expression levels showed significant association with cervical cancer in specific immune cell types, respectively. These associations were supported by strong evidence of colocalization analyses. Our study has identified several genes in different immune cells that were associated with cervical cancer. However, further research is necessary to confirm these findings and provide more comprehensive insights into the association between these gene expressions and cervical cancer risk.

High performance of the DNA methylation‐based WID‐qEC test for detecting uterine cancers independent of sampling modalities

AbstractEndometrial cancer (EC) is the most prevalent gynaecological cancer in high‐income countries and its incidence is continuing to rise sharply. Simple and objective tools to reliably detect women with EC are urgently needed. We recently developed and validated the DNA methylation (DNAme)‐based women's cancer risk identification—quantitative polymerase chain reaction test for endometrial cancer (WID‐qEC) test that could address this need. Here, we demonstrate that the stability of the WID‐qEC test remains consistent regardless of: (i) the cervicovaginal collection device and sample media used (Cervex brush and PreservCyt or FLOQSwab and eNAT), (ii) the collector of the specimen (gynaecologist‐ or patient‐based), and (iii) the precise sampling site (cervical, cervicovaginal and vaginal). Furthermore, we demonstrate sample stability in eNAT medium for 7 days at room temperature, greatly facilitating the implementation of the test into diagnostic laboratory workflows. When applying FLOQSwabs (Copan) in combination with the eNAT (Copan) sample collection media, the sensitivity and specificity of the WID‐qEC test to detect uterine (i.e., endometrial and cervical) cancers in gynaecologist‐taken samples was 92.9% (95% confidence interval [CI] = 75.0%–98.8%) and 98.6% (95% CI = 91.7%–99.9%), respectively, whilst the sensitivity and specificity in patient collected self‐samples was 75.0% (95% CI = 47.4%–91.7%) and 100.0% (95% CI = 93.9%–100.0%), respectively. Taken together these data confirm the robustness and clinical potential of the WID‐qEC test.

Differential levels of circulating RNAs prior to endometrial cancer diagnosis

AbstractEndometrial cancer (EC) is one of the most common female cancers and there is currently no routine screening strategy for early detection. An altered abundance of circulating microRNAs (miRNAs) and other RNA classes have the potential as early cancer biomarkers. We analyzed circulating RNA levels using small RNA sequencing, targeting RNAs in the size range of 17–47 nucleotides, in EC patients with samples collected prior to diagnosis compared to cancer‐free controls. The analysis included 316 cases with samples collected 1–11 years prior to EC diagnosis, and 316 matched controls, both from the Janus Serum Bank cohort in Norway. We identified differentially abundant (DA) miRNAs, isomiRs, and small nuclear RNAs between EC cases and controls. The top EC DA miRNAs were miR‐155‐5p, miR‐200b‐3p, miR‐589‐5p, miR‐151a‐5p, miR‐543, miR‐485‐5p, miR‐625‐p, and miR‐671‐3p. miR‐200b‐3p was previously reported to be among one of the top miRNAs with higher abundance in EC cases. We observed 47, 41, and 32 DA miRNAs for EC interacting with BMI, smoking status, and physical activity, respectively, including two miRNAs (miR‐223‐3p and miR‐29b‐3p) interacting with all three factors. The circulating RNAs are altered and show temporal dynamics prior to EC diagnosis. Notably, DA miRNAs for EC had the lowest q‐value 4.39–6.66 years before diagnosis. Enrichment analysis of miRNAs showed that signaling pathways Fc epsilon RI, prolactin, toll‐like receptor, and VEGF had the strongest associations.

Estimating the direct effect of human papillomavirus vaccination on the lifetime risk of screen‐detected cervical precancer

AbstractBirth cohorts vaccinated against human papillomavirus (HPV) are now entering cervical cancer screening. Assessment of (pre)cancer (CIN3+) risk is needed to assess the residual screening need in vaccinated women. We estimated the lifetime (screen‐detected) CIN3+ risk under five‐yearly primary HPV screening between age 30 and 60, using HPV genotyping and histology data of 21,287 women participating in a screening trial with two HPV‐based screening rounds, 5 years apart. The maximum follow‐up after an HPV‐positive test was 9 years. We re‐estimated the CIN3+ risk after projecting direct vaccine efficacy for the bivalent and the nonavalent HPV vaccines, assuming life‐long protection. The lifetime CIN3+ risk was 4.1% (95% confidence interval 3.5‐4.9) and declined by 53.5% and 70.5% after bivalent vaccination without and with cross‐protection, respectively, translating into a residual lifetime CIN3+ risk of 1.9% (1.4‐2.4) and 1.2% (0.9‐1.5). The CIN3+ risk declined by 88.5% after nonavalent vaccination, translating into a residual lifetime CIN3+ risk of 0.5% (0.2‐0.7). The latter risk increased to 1.6% when vaccine protection only lasted until the first screening round at age 30. Among HPV‐positive women with abnormal adjunct cytology, the nine‐year CIN3+ risk was 16.9% (8.7‐32.4) after nonavalent vaccination. In conclusion, HPV vaccination will lead to a strong decline in the lifetime CIN3+ risk and the remaining absolute CIN3+ risk will be very low. Primary HPV testing combined with adjunct cytology at five‐year intervals still seems feasible even after nonavalent vaccination, although unlikely to be cost‐effective. Our results support a de‐intensification of screening programs in settings with high vaccination coverage.

Molecular analysis of the evolutionary history of endometrial and ovarian carcinoma in Lynch syndrome

AbstractLynch syndrome (LS) is a prevalent cause of hereditary gynecological cancers. DNA mismatch repair (MMR) defects are important players in LS tumorigenesis, but the developmental steps leading to malignancy are incompletely understood. We undertook a deep sequencing approach with a panel of ~1,000 cancer‐associated genes to detect somatic changes in retrospective specimens from 33 LS carriers who had developed endometrial carcinoma (EC) or ovarian carcinoma (OC). Consecutive samples of atypical endometrial hyperplasia (AH) and EC or OC (64 samples plus blood) were available from a screening period of 15 years (0–15 years). Of carcinomas, all but one (41/42, 98%) were MMR‐deficient by microsatellite instability or immunohistochemical analysis, and 86% (36/42) showed loss of heterozygosity or somatic variants of MMR genes as putative second hits. AH closely resembled EC and OC with respect to MMR deficiency (20/22, 91%) and the presence of second hits (16/22, 73%); moreover, the average tumor mutation burdens and top mutant genes were largely similar in hyperplasia and carcinoma. The proportion of hypermutated tumors (over 10 somatic non‐synonymous mutations per megabase) was 36/42 (86%) among carcinomas and 15/22 (68%) among hyperplasia specimens (statistically non‐significant difference). In individual patients, cancer‐associated genes revealed varying degrees of somatic variant sharing between consecutive specimens of hyperplasia and carcinoma (10/19, 53%), and in some, such variants were detectable in histologically normal endometrium (9/19, 47%) too, one or several years before carcinoma. Our results shed light on the evolutionary trajectories of gynecological cancer development in LS.

Comparative sequencing study of mismatch repair and homology‐directed repair genes in endometrial cancer and breast cancer patients from Kazakhstan

AbstractEndometrial cancer has been associated with pathogenic variants in mismatch repair (MMR) genes, especially in the context of the hereditary Lynch Syndrome. More recently, pathogenic variants in genes of homology‐directed repair (HDR) have also been suggested to contribute to a subset of endometrial cancers. In the present hospital‐based study, we investigated the relative distribution of pathogenic MMR or HDR gene variants in a series of 342 endometrial cancer patients from the Oncology Clinic in Almaty, Kazakhstan. In comparison, we also sequenced 178 breast cancer patients from the same population with the same gene panel. Identified variants were classified according to ClinVar, ESM1b, and AlphaMissense prediction tools. We found 10 endometrial cancer patients (2.9%) carrying pathogenic or likely pathogenic variants in MMR genes (7 MSH6, 1 MSH2, 2 MUTYH), while 14 endometrial cancer patients (4.1%) carried pathogenic variants in HDR genes (4 BRCA2, 3 BRCA1, 3 FANCM, 2 SLX4, 1 BARD1, 1 BRIP1). In the breast cancer series, we found 8 carriers (4.5%) of pathogenic or likely pathogenic variants in MMR genes (2 MSH2, 2 MSH6, 4 MUTYH) while 12 patients (6.7%) harbored pathogenic or likely pathogenic HDR gene variants (5 BRCA1, 3 BRCA2, 1 BRIP1, 1 ERRC4, 1 FANCM, 1 SLX4). One patient who developed breast cancer first and endometrial cancer later carried a novel frameshift variant in MSH6. Our results indicate that MMR and HDR gene variants with predicted pathogenicity occur at substantial frequencies in both breast and endometrial cancer patients from the Kazakh population.

The WID‐EC test for the detection and risk prediction of endometrial cancer

AbstractThe incidence of endometrial cancer is rising. Measures to identify women at risk and to detect endometrial cancer earlier are required to reduce the morbidity triggered by the aggressive treatment required for advanced endometrial cancer. We developed the WID‐EC (Women's cancer risk IDentification‐Endometrial Cancer) test, which is based on DNA methylation at 500 CpG sites, in a discovery set of cervical liquid‐based cytology samples from 1086 women with and without an endometrial cancer (217 cancer cases and 869 healthy controls) with a worse prognosis (grade 3 or ≥stage IB). We validated the WID‐EC test in an independent external validation set of 64 endometrial cancer cases and 225 controls. We further validated the test in 150 healthy women (prospective set) who provided a cervical sample as part of the routine Swedish cervical screening programme, 54 of whom developed endometrial cancer within 3 years of sample collection. The WID‐EC test identified women with endometrial cancer with a receiver operator characteristic area under the curve (AUC) of 0.92 (95% CI: 0.88‐0.97) in the external set and of 0.82 (95% CI: 0.74‐0.89) in the prospective validation set. Using an optimal cutoff, cancer cases were detected with a sensitivity of 86% and a specificity of 90% in the external validation set, and a sensitivity and specificity of 52% and 98% respectively in the prospective validation set. The WID‐EC test can identify women with or at risk of endometrial cancer.

Declining rates of cervical intraepithelial neoplasia in British Columbia, Canada: An ecological analysis on the effects of the school‐based human papillomavirus vaccination program

AbstractSince 2008, girls in British Columbia (BC), Canada, have been offered HPV vaccination through a school‐based, publicly funded immunization program. The oldest birth cohort eligible for the vaccination program was born in 1994 and uptake is on average 63%. To evaluate the impact of the HPV vaccine in BC, ecological trends in cervical intraepithelial neoplasia (CIN) rates were assessed in young women before and after the implementation of the HPV vaccination program. Information on all Pap smears and histopathological abnormalities, in calendar years 2004‐2017 in women 16‐28 years of age in BC were obtained from the population‐based BC Cancer Cervix Screening Program database. Rates of CIN 2 and 3 were calculated as the number of cases divided by the number of cytology specimens for that period. Rate ratios (RR) were calculated by negative binomial piecewise regression. Age‐centered incidence rates of CIN 2 and 3 in BC declined significantly among women 16‐23 years of age after HPV vaccine introduction compared to before vaccine introduction. The overall reduction postvaccination for CIN2 and 3 in women 16‐23 years was respectively 62% (95% CI 54‐68%) and 65% (95% CI 58‐71%). Age‐specific rates for CIN2 significantly declined for those 18‐22 years of age and for those 19, 20 and 23 years of age for CIN3. Among women 24‐28 years of age no decline in CIN2 and 3 rate over time was observed. The observed reduction in CIN 2 and 3 rates since the introduction of the school‐based HPV vaccine program might illustrate the population impact of the BC provincial school‐based HPV vaccination program.

Systemic circulating microRNA landscape in Lynch syndrome

Abstract Circulating microRNAs (c‐miRs) are small noncoding RNA molecules that migrate throughout the body and regulate gene expression. Global c‐miR expression patterns (c‐miRnomes) change with sporadic carcinogenesis and have predictive potential in early detection of cancers. However, there are no studies that have assessed whether c‐miRnomes display similar potential in carriers of inherited pathogenic mismatch‐repair gene variants ( path_MMR ), known as Lynch syndrome (LS), who are predisposed to highly increased cancer risk. Using high‐throughput sequencing and bioinformatic approaches, we conducted an exploratory analysis to characterize systemic c‐miRnomes of path_MMR carriers, sporadic rectal cancer patients and non‐LS controls. We showed for the first time that cancer‐free path_MMR carriers have a systemic c‐miRnome of 40 differentially expressed c‐miRs that can distinguish them from non‐LS controls. The systemic c‐miRnome of cancer‐free path_MMR carriers also resembles the systemic c‐miRnomes of cancer patients with or without path_MMR . Our pathway analysis linked the found differentially expressed c‐miRs to carcinogenesis. A total of 508 putative target genes were identified for 32 out of 40 differentially expressed c‐miRs, and 238 of them were enriched in cancer‐related pathways. The most enriched c‐miR‐target genes include well‐known oncogenes and tumor suppressor genes such as BCL2 , AKT3 , PIK3CA , KRAS , NRAS , CDKN1A and PIK3R1 . Taken together, our findings suggest that LS and sporadic carcinogenesis share common biological pathways and alterations in these pathways can produce a c‐miR signature which can track potential oncogenic stress in cancer‐free path_MMR carriers. Therefore, c‐miRs hold potential in monitoring the LS risk stratification patterns during clinical surveillance or cancer management.

L1CAM expression as a predictor of platinum response in high‐risk endometrial carcinoma

AbstractFor high‐risk endometrial cancer (EC) patients, adjuvant chemotherapy is recommended to improve outcome. Yet, predictive biomarkers for response to platinum‐based chemotherapy (Pt‐aCT) are currently lacking. We tested expression of L1 cell‐adhesion molecule (L1CAM), a well‐recognised marker of poor prognosis in EC, in tumour samples from high‐risk EC patients, to explore its role as a predictive marker of Pt‐aCT response. L1CAM expression was determined using RT‐qPCR and immunohistochemistry in a cohort of high‐risk EC patients treated with Pt‐aCT and validated in a multicentric independent cohort. The association between L1CAM and clinicopathologic features and L1CAM additive value in predicting platinum response were determined. The effect of L1CAM gene silencing on response to carboplatin was functionally tested on primary L1CAM‐expressing cells. Increased L1CAM expression at both genetic and protein level correlated with high‐grade, non‐endometrioid histology and poor response to platinum treatment. A predictive model adding L1CAM to prognostic clinical variables significantly improved platinum response prediction (C‐index 78.1%, P = .012). In multivariate survival analysis, L1CAM expression was significantly associated with poor outcome (HR: 2.03, P = .019), potentially through an indirect effect, mediated by its influence on response to chemotherapy. In vitro, inhibition of L1CAM significantly increased cell sensitivity to carboplatin, supporting a mechanistic link between L1CAM expression and response to platinum in EC cells. In conclusion, we have demonstrated the role of L1CAM in the prediction of response to Pt‐aCT in two independent cohorts of high‐risk EC patients. L1CAM is a promising candidate biomarker to optimise decision making in high‐risk patients who are eligible for Pt‐aCT.

Endometrial cancer prognosis in women with endometriosis and adenomyosis: A retrospective nationwide cohort study of 40 840 women

AbstractWe aim to compare endometrial cancer survival in women with or without histological proven endometriosis or adenomyosis. We identified all women with endometrial cancer between 1990 and 2015 from the Netherlands Cancer Registry (NCR). Data were linked to the Dutch pathology database (PALGA) to select all women with histological proven endometriosis/adenomyosis. Overall survival was compared between women with endometrial cancer with or without endometriosis/adenomyosis. We used multivariable Cox proportional hazard analysis to estimate hazard ratios (HRs). We included 1701 women with endometrial cancer and endometriosis/adenomyosis, of whom 1236 (72.7%) women had adenomyosis, 320 (18.8%) had endometriosis and 145 (8.5%) had both. We compared these women to 39 139 women with endometrial cancer without endometriosis/adenomyosis. Women in the combined endometriosis/adenomyosis cohort were younger at endometrial cancer diagnosis, had earlier disease stage, more often had endometrioid endometrial cancer and low grade tumors. The 5‐year survival rate in the combined endometriosis/adenomyosis cohort was 84.8% (95% CI 84.6‐88.1) and 71.6% (95% CI 71.1‐72.0) in the nonendometriosis/adenomyosis cohort. Univariable analysis resulted in a crude HR of 0.63 (95% CI 0.59‐0.69). Significant confounding factors were age, stage, cancer subtype, histological grading, surgery and chemotherapy rate. Correction for these confounders resulted in a HR of 0.98 (95% CI 0.90‐1.06). Including endometriosis/adenomyosis status as a categorical factor resulted in similar HRs. In conclusion, women with endometrial cancer and histologically proven endometriosis/adenomyosis have a better overall survival when compared to women with endometrial cancer without endometriosis/adenomyosis. This better survival was correlated to stage, grade, age and histological subtype, but not to the presence of endometriosis/adenomyosis.

Cervical cancer prevention becomes more efficient

Projected cancer burden attributable to population aging: Insight from a rapidly aging society

Abstract Population aging is an increasing challenge for cancer control in rapidly aging societies, yet remains inadequately quantified. We aim to project and illustrate the cancer burden attributable to aging in Korea by utilizing age‐period‐cohort (APC) models and population attributable fraction (PAF) concepts. From population‐based cancer data, incidence and mortality of cancers primarily affected by aging (stomach, colorectal, liver, gallbladder, pancreatic, lung, non‐Hodgkin lymphoma, esophagus, prostate, ovarian, male bladder cancers, and female leukemia) and breast cancer were extracted. Aging‐attributable fraction, cases, and deaths were estimated for older ages after projection to 2046 by APC models. Future cancer landscapes were projected to evolve due to population aging. While aging‐related lung cancer may remain the highest (from 2017–2021: 94,990 cases, 71,726 deaths, PAF mortality 78%; to 2042–2046: 220,251 cases, PAF incidence 78%, 114,476 deaths, PAF mortality 88%), the current high burden of stomach and liver cancers, likely related to infection, will shift to older age with reduced aging‐attributable cases but increased PAF incidence . Emerging burden will arise from lifestyle‐related cancers, including colorectal cancer mortality (mortality‐to‐incidence ratio [MIR] of age ≥65 0.41 to 0.46) and prostate and breast cancer incidence (for age ≥65: 60,099 to 228,539 cases, PAF incidence 74% to 86%; and 1316 to 31,874 cases, PAF incidence 1% to 22%, respectively). Our findings highlight the coexistence of traditional and emerging burdens, which should be key priorities for cancer control programs when societies enter the upcoming super‐aged decades. Efforts to mitigate forecasted trends are urgently required, including cancer prevention targeting middle‐aged adults and cancer care for frail older patients.

Can miRNAs be useful biomarkers in improving prognostic stratification in endometrial cancer patients? An update review

AbstractEndometrial cancer (EC) is the most common gynecological cancer, with annual incidence rates in Western countries ranging between 15 and 25 per 100 000 women. About 15% to 20% of patients with EC have high‐risk disease and follow an aggressive clinical course. Unfortunately, the assessment of histologic parameters is poorly reproducible and conventional clinicopathological and molecular features do not reliably predict either the patient's response to the available treatments or the definition of personalized therapeutic approaches. In this context, the identification of novel diagnostic and prognostic biomarkers, which can be integrated in the current classification schemes, represents an unmet clinical need and an important challenge. miRNAs are key players in cancer by regulating the expression of specific target genes. Their role in EC, in association with clinical and prognostic tumor biomarkers, has been investigated but, so far, with little consensus among the studies. The present review aims to describe the recent advances in miRNAs research in EC taking into consideration the current classification schemes and to highlight the most promising miRNAs. Finally, a perspective point of view sheds light on the challenges ahead in the landscape of EC.

Circulating adipokine concentrations and risk of five obesity‐related cancers: A Mendelian randomization study

AbstractObesity is considered a chronic inflammatory state characterized by continued secretion of adipokines and cytokines. Experimental and epidemiological evidence indicates that circulating adipokines may be associated with the development of obesity‐related cancers, but it is unclear if these associations are causal or confounded. We examined potential causal associations of specific adipokines (adiponectin, leptin, soluble leptin receptor [sOB‐R] and plasminogen activator inhibitor‐1 [PAI‐1]) with five obesity‐related cancers (colorectal, pancreatic, renal cell carcinoma [RCC], ovarian and endometrial) using Mendelian randomization (MR) methods. We used summary‐level data from large genetic consortia for 114 530 cancer cases and 245 284 controls. We constructed genetic instruments using 18 genetic variants for adiponectin, 2 for leptin and 4 for both sOB‐R and PAI‐1 (P value for inclusion<5 × 10−8). Causal estimates were obtained using two‐sample MR methods. In the inverse‐variance weighted models, we found an inverse association between adiponectin and risk of colorectal cancer (odds ratio per 1 μg/mL increment in adiponectin concentration: 0.90 [95% confidence interval = 0.84‐0.97]; P = .01); but, evidence of horizontal pleiotropy was detected and the association was not present when this was taken into consideration. No association was found for adiponectin and risks of pancreatic cancer, RCC, ovarian cancer and endometrial cancer. Leptin, sOB‐R and PAI‐1 were also similarly unrelated to risk of obesity‐related cancers. Despite the large sample size, our MR analyses do not support causal effects of circulating adiponectin, leptin, sOB‐R and PAI‐1 concentrations on the development of five obesity‐related cancers.

Weight change in middle adulthood and risk of cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort

AbstractObesity is a risk factor for several major cancers. Associations of weight change in middle adulthood with cancer risk, however, are less clear. We examined the association of change in weight and body mass index (BMI) category during middle adulthood with 42 cancers, using multivariable Cox proportional hazards models in the European Prospective Investigation into Cancer and Nutrition cohort. Of 241 323 participants (31% men), 20% lost and 32% gained weight (>0.4 to 5.0 kg/year) during 6.9 years (average). During 8.0 years of follow‐up after the second weight assessment, 20 960 incident cancers were ascertained. Independent of baseline BMI, weight gain (per one kg/year increment) was positively associated with cancer of the corpus uteri (hazard ratio [HR] = 1.14; 95% confidence interval: 1.05‐1.23). Compared to stable weight (±0.4 kg/year), weight gain (>0.4 to 5.0 kg/year) was positively associated with cancers of the gallbladder and bile ducts (HR = 1.41; 1.01‐1.96), postmenopausal breast (HR = 1.08; 1.00‐1.16) and thyroid (HR = 1.40; 1.04‐1.90). Compared to maintaining normal weight, maintaining overweight or obese BMI (World Health Organisation categories) was positively associated with most obesity‐related cancers. Compared to maintaining the baseline BMI category, weight gain to a higher BMI category was positively associated with cancers of the postmenopausal breast (HR = 1.19; 1.06‐1.33), ovary (HR = 1.40; 1.04‐1.91), corpus uteri (HR = 1.42; 1.06‐1.91), kidney (HR = 1.80; 1.20‐2.68) and pancreas in men (HR = 1.81; 1.11‐2.95). Losing weight to a lower BMI category, however, was inversely associated with cancers of the corpus uteri (HR = 0.40; 0.23‐0.69) and colon (HR = 0.69; 0.52‐0.92). Our findings support avoiding weight gain and encouraging weight loss in middle adulthood.

Molecular profiling identifies synchronous endometrial and ovarian cancers as metastatic endometrial cancer with favorable clinical outcome

Synchronous primary endometrial and ovarian cancers (SEOs) represent 10% of all endometrial and ovarian cancers and are assumed to develop as independent entities. We investigated the clonal relationship between endometrial and ovarian carcinomas in a large cohort classified as SEOs or metastatic disease (MD). The molecular profiles were compared to The Cancer Genome Atlas (TCGA) data to explore primary origin. Subsequently, the molecular profiles were correlated with clinical outcome. To this extent, a retrospective multicenter study was performed comparing patients with SEOs (n = 50), endometrial cancer with synchronous ovarian metastasis (n = 19) and ovarian cancer with synchronous endometrial metastasis (n = 20). Targeted next‐generation sequencing was used, and a clonality index was calculated. Subsequently, cases were classified as POLE mutated, mismatch repair deficient (MMR‐D), TP53‐wild‐type or TP53‐mutated. In 92% of SEOs (46/50), the endometrial and concurrent ovarian carcinoma shared at least one somatic mutation, with a clonality index above 0.95, supporting a clonal origin. The SEO molecular profiles showed striking similarities with the TCGA endometrial carcinoma set. SEOs behaved distinctly different from metastatic disease, with a superior outcome compared to endometrial MD cases (p < 0.001) and ovarian MD cases (p < 0.001). Classification according to the TCGA identified four groups with different clinical outcomes. TP53 mutations and extra‐utero‐ovarian disease were independent predictors for poor clinical outcome. Concluding, SEOs were clonally related in an overwhelming majority of cases and showed a favorable prognosis. Their molecular profile implied a primary endometrial origin. TP53 mutation and extra‐utero‐ovarian disease were independent predictors for outcome, and may impact adjuvant systemic treatment planning.

Body size, body composition and endometrial cancer risk among postmenopausal women in UK Biobank

AbstractPrevious studies on the association of adiposity with endometrial cancer risk have mostly used body mass index (BMI) as the main exposure of interest. Whether more precise measures of body fat, such as body fat percentage and fat mass estimated by bioimpedance analyses, are better indicators of risk than BMI is unknown. The role of central adiposity and fat‐free mass in endometrial cancer development remains unclear. We used Cox regression models to estimate hazard ratios (HR) and corresponding 95% confidence intervals (CI) for the associations of various measures of body size/composition with the risk of endometrial cancer among 135 110 postmenopausal women enrolled in UK Biobank. During a mean follow up of 6.8 years, 706 endometrial cancers were diagnosed, with a mean age at diagnosis of 65.5 years. The HRs (95% CIs) for endometrial cancer per 1 SD increase in BMI, body fat percentage and fat mass were broadly comparable, being 1.71 (1.61‐1.82), 1.92 (1.75‐2.11) and 1.73 (1.63‐1.85), respectively. There was an indication of positive association between central adiposity, as reflected by waist circumference (HRper 1‐SD increase = 1.08, 95% CI: 1.00‐1.17) and waist to hip ratio (HRper 1‐SD increase = 1.13, 95% CI: 1.01‐1.26), and endometrial cancer risk after accounting for BMI. Fat‐free mass was not an independent predictor of risk in this cohort. These findings suggest that body fat percentage and fat mass are not better indicators of endometrial cancer risk than BMI. Further studies are needed to establish whether central adiposity contributes to risk beyond overall adiposity.

Theoretical potential for endometrial cancer prevention through primary risk factor modification: Estimates from the EPIC cohort

Endometrial cancer (EC) incidence rates vary ~10‐fold worldwide, in part due to variation in EC risk factor profiles. Using an EC risk model previously developed in the European EPIC cohort, we evaluated the prevention potential of modified EC risk factor patterns and whether differences in EC incidence between a European population and low‐risk countries can be explained by differences in these patterns. Predicted EC incidence rates were estimated over 10 years of follow‐up for the cohort before and after modifying risk factor profiles. Risk factors considered were: body mass index (BMI, kg/m2), use of postmenopausal hormone therapy (HT) and oral contraceptives (OC) (potentially modifiable); and, parity, ages at first birth, menarche and menopause (environmentally conditioned, but not readily modifiable). Modeled alterations in BMI (to all ≤23 kg/m2) and HT use (to all non‐HT users) profiles resulted in a 30% reduction in predicted EC incidence rates; individually, longer duration of OC use (to all ≥10 years) resulted in a 42.5% reduction. Modeled changes in not readily modifiable exposures (i.e., those not contributing to prevention potential) resulted in ≤24.6% reduction in predicted EC incidence. Women in the lowest decile of a risk score based on the evaluated exposures had risk similar to a low risk countries; however, this was driven by relatively long use of OCs (median = 23 years). Our findings support avoidance of overweight BMI and of HT use as prevention strategies for EC in a European population; OC use must be considered in the context of benefits and risks.

Cost‐effectiveness analysis of alternative screening strategies for the detection of cervical cancer among women in rural areas of Western Kenya

AbstractWhile the incidence of cervical cancer has dropped in high‐income countries due to organized cytology‐based screening programs, it remains the leading cause of cancer death among women in Eastern Africa. Therefore, the World Health Organization (WHO) now urges providers to transition from widely prevalent but low‐performance visual inspection with acetic acid (VIA) screening to primary human papillomavirus (HPV) DNA testing. Due to high HPV prevalence, effective triage tests are needed to identify those lesions likely to progress and so avoid over‐treatment. To identify the optimal cost‐effective strategy, we compared the VIA screen‐and‐treat approach to primary HPV DNA testing with p16/Ki67 dual‐stain cytology or VIA as triage. We used a Markov model to calculate the budget impact of each strategy with incremental quality‐adjusted life years and incremental cost‐effectiveness ratios (ICER) as the main outcome. Deterministic cost‐effectiveness analyses show that the screen‐and‐treat approach is highly cost‐effective (ICER 2469 Int$), while screen, triage, and treat with dual staining is the most effective with favorable ICER than triage with VIA (ICER 9943 Int$ compared with 13,177 Int$). One‐way sensitivity analyses show that the results are most sensitive to discounting, VIA performance, and test prices. In the probabilistic sensitivity analyses, the triage option using dual stain is the optimal choice above a willingness to pay threshold of 7115 Int$ being cost‐effective as per WHO standards. The result of our analysis favors the use of dual staining over VIA as triage in HPV‐positive women and portends future opportunities and necessary research to improve the coverage and acceptability of cervical cancer screening programs.

Predicting optimal impact interventions in the post‐ HPV vaccination world

Abstract Prophylactic vaccination is a powerful tool that changes exposure to infections and associated morbidity of preventable diseases. We discuss the impact of pneumococci and human papillomavirus (HPV) vaccination on the population biology of the two micro‐organisms and related public health effects. Data on HPV type‐replacement in communities where vaccine‐covered HPVs are almost eliminated, and interactions of the remaining HPV types on the risk of cervical cancer are reviewed. Results of comprehensive models for European country‐specific conduction of cervical screening among HPV‐vaccinated and unvaccinated women, assuming different HPV‐vaccination coverage and strategies, are discussed in our policy‐oriented review. An acceptable balance of benefits and harms of cervical cancer screening in HPV vaccinated populations requires an understanding of cancer risks in differently vaccinated birth cohorts. Finally, the challenges are complex but can be met if strategies are applied that (i) as fast as possible achieve herd effect and (ii) use a risk‐based design of HPV screening.

Cancer detection using human papillomavirus self‐sampling targeting long‐term non‐attenders in an organized cervical screening program

Abstract Self‐sampling for human papillomavirus (HPV) is an established strategy to increase participation in cervical screening. We previously reported a randomized trial targeting women who had not attended screening after >10 invitations, where sending of self‐sampling kits resulted in a 19% attendance and a positive predictive value (PPV) for high grade lesions (HSIL+) of 40%, despite no triaging after the HPV test. Because of the striking results, the intervention was extended to all women resident in Stockholm County, Sweden, in the years 2019/20, who had not attended screening >10 years ( N  = 42,409). Participation was 35.6% and 11.6% of the participating women were HPV‐positive. Among these, there were 43 cases of invasive cervical cancer and 319 cases of high‐grade lesions. The PPV was particularly high for HPV16/18 positive women (12% for invasive cancer and 59% for HSIL). In summary, participation with HPV self‐sampling among long‐term non‐attenders in the real‐life program was considerably higher than in the research setting and the high yield of HSIL+ implied high effectiveness.

Indicators to identify cancer screening providers with suboptimal case detection: A scoping review

Abstract Several international guidelines consider sensitivity (of test, episode, or programme) and related measures of the detection of prevalent cases of target disease to be among key performance indicators for quality control of routine cancer screening programmes and use them to identify suboptimal providers. We aimed to describe the variability encountered in real‐world settings around the measurement of these quantities in cervical and colorectal cancer screening, where the target for disease detection includes preinvasive disease. We performed a scoping review of grey literature, including international guidelines, annual statistical reports, and other official documents from European cervical and colorectal screening programmes. From the reviewed material, we extracted information on 20 measures used for this purpose. Some measures have been adopted in several programmes, but none have been used in all, not even within the same cancer type. While many of the methods might appear plausible for the intended use, our analysis showed that when applied to routinely collected data they may provide misleading or uninterpretable estimates of the ability of individual providers and the service as a whole to detect prevalent cases. Screening programmes should be cautious in their choice and interpretation of these measures. Further methodological development is required to better support policymakers and quality control managers in prioritising measures that are fit for purpose in routine cancer screening programmes.

Enhanced diagnostic accuracy of high‐grade cervical intraepithelial neoplasia in postmenopausal women through PAX1 / JAM3 methylation analysis

Abstract This study aimed to assess the diagnostic‐support and triage value of PAX1/JAM3 methylation testing for identifying high‐grade cervical lesions among postmenopausal women referred for colposcopy. A total of 216 women aged ≥50 years who underwent colposcopy due to positive high‐risk human papillomavirus (hrHPV)/cytology detection and/or abnormal clinical symptoms were included, and 212 women aged <50 years matched 1:1 by hrHPV and cytology results as the control group. The effectiveness of PAX1 / JAM3 methylation in detecting high‐grade cervical intraepithelial neoplasia (CIN) was compared to traditional screening methods. PAX1/JAM3 methylation showed a sensitivity of 93.2%[85.7%–100%] for detecting CIN2+ lesions (97.2%[91.9%–100%] for CIN3+), with a specificity of 93.6%[89.9%–97.3%] for CIN1‐lesions, outperforming liquid‐based cytology (LBC) (CIN2+/CIN3+ sensitivity: 75%[60.9%–89.1%]; specificity: 52.3%[44.9%–59.8%]) and the combination of LBC and hrHPV tests according to current guidelines (CIN2+/CIN3+ sensitivity: 81.8%[70.4%–93.2%]/83.3%[71.2%–95.5%]; specificity: 45.3%[37.9%–52.8%]). Methylation detection successfully identified two adenocarcinoma cases with negative hrHPV and LBC, as well as 7 patients with non‐16/18 hrHPV infection that were missed by LBC. The methylation levels of PAX1 and JAM3 were elevated in elderly women with CIN2+ compared to younger women, and showed no association with HPV types. In conclusion, PAX1/JAM3 methylation testing showed promising diagnostic‐support performance among postmenopausal women referred for colposcopy, suggesting potential utility as a supplementary detection method to improve diagnostic accuracy in older women.

Sustained impact of bivalent HPV immunisation on CIN incidence over two rounds of cervical screening

Abstract Vaccination against high‐risk HPV has been shown to reduce significantly the incidence of pre‐invasive and invasive cervical disease. Clinical trials show immunity and vaccine effectiveness for over 12 years but real‐life longitudinal data are lacking. Vaccination with the bivalent vaccine (3 dose schedule) for women aged 12–18 years began in Scotland in 2008; immunised women entered screening in 2010. Women immunised at age12–13 years entered screening in 2015. Linked data from ≤12 years of routine screening activity shows adjusted VE against CIN2+ at age 12–13 of 72·6% (95%CI: 67.7–76.8) and at age 14–16 of 63·2 (CI 60·4–65·8), and against CIN3+ of 81·7 (CI 76·2–78·6; age 12–13) and 68·1 (CI 64·1–71·6; age 14–16) after 3 doses or two doses 5 months apart. Adjusted VE following two doses 1 month apart or one dose only at age14 was 20.5 (95%CI: 6.1–32.6) for CIN2+ and 34.9 (95%CI:17.0–48.9) for CIN3+. No benefit was seen with vaccination over the age of 18 years. The most deprived women showed the highest incidence of CIN2+ and CIN3+, and the greatest reduction in CIN2+ and CIN3+ following complete immunisation. Herd protection is seen in all immunised cohorts. This population based analysis confirms the long‐term effectiveness of the bivalent HPV vaccine, greatest in women from the most deprived areas and reinforces the importance of ensuring high vaccine uptake rates at an early age.

The impact of loss to follow‐up in the Dutch organised HPV‐based cervical cancer screening programme

AbstractLoss to follow‐up (LTFU) within cervical screening programmes can result in missed clinically relevant lesions, potentially reducing programme effectiveness. To examine the health impact of losing women during the screening process, we determined the proportion of women LTFU per step of the Dutch hrHPV‐based screening programme. We then determined the probability of being LTFU by age, screening history and sampling method (self‐ or clinician‐sampled) using logistic regression analysis. Finally, we estimated the number of missed CIN2+/3+ lesions per LTFU moment by using the CIN‐risk in women compliant with follow‐up. Data from the Dutch nationwide pathology databank (Palga) was used. Women eligible for screening in 2017 and 2018 were included (N = 840,428). For clinician collected (CC) samples, the highest proportion LTFU was found following ‘referral advice for colposcopy’ (5.5% after indirect referral; 3.8% after direct referral). For self‐sampling, the highest proportions LTFU were found following the advice for repeat cytology (13.6%) and after referral advice for colposcopy (8.2% after indirect referral; 4.3% after direct referral). Self‐sampling users and women with no screening history had a higher LTFU‐risk (OR: 3.87, CI: 3.55–4.23; OR: 1.39, CI: 1.20–1.61) compared to women that used CC sampling and women that have been screened before, respectively. Of all women LTFU in 2017/18, the total number of potentially missed CIN2+ was 844 (21% of women LTFU). Most lesions were missed after ‘direct referral for colposcopy’ (N = 462, 11.5% of women LTFU). So, this indicates a gap between the screening programme and clinical care which requires further attention, by improving monitoring of patients after referral.

Under which realistic circumstances is hrHPV self‐sampling increasing cervical screening effectiveness in a partly vaccinated population? A modelling study

Abstract High‐risk Human Papillomavirus self‐sampling can increase attendance rates for screening. However, observed lower sensitivity and loss to follow‐up of self‐sampling could reduce programme effectiveness when attenders of clinician‐collected sampling switch to self‐sampling. We determined the tipping point for effectiveness (based on life years gained [LYG]) of self‐sampling and the consequences for cost‐effectiveness, taking into account waste by comparing full opt‐out (no waste) to no opt‐out (waste from unused self‐sampling kits). We used the STDSIM‐MISCAN‐Cervix microsimulation model to simulate a population of Dutch women born in 2000 (50% vaccinated [sensitivity analysis: 0–100%], 70% screening attendance [sensitivity analysis: 60–80%]). Self‐sampling deployment strategies (e.g., direct‐mail) were varied by the percentage of original attenders switching to self‐sampling and the percentage of new attendance from non‐attenders. Main outcome measures were LYG and cost‐effectiveness (cost per quality adjusted [QA] LY gained) compared to the current programme. We found that if self‐sampling does not reach non‐attenders, life years cannot be gained. When reaching 10% or 30% of non‐attenders, the tipping point lies at ≤40% and ≤100% switchers to maintain effectiveness, respectively (+4 LYG, +10 LYG). Scenarios were cost‐effective (<€50,000/QALY gained) if at least 10% of non‐attenders were reached. Full opt‐out improved cost‐effectiveness substantially. So, in a partly vaccinated population, self‐sampling deployment strategies need to reach at least 10% of non‐attenders to maintain programme effectiveness and cost‐effectiveness. A well‐functioning opt‐out system further improves cost‐effectiveness by preventing waste.

Evaluation of targeted next‐generation sequencing for detection of HPV genotypes and sublineages in cervical liquid‐based cytology SurePath samples from the Danish screening program

Abstract The carcinogenicity of HPV genotypes is well established. However, HPV genotypes have sublineages with individual risk profiles, and these are much less described with respect to carcinogenicity. Research to characterize HPV sublineages by next‐generation sequencing (NGS) on screening‐derived liquid‐based cytology (LBC) samples is limited because of the technical and quality assurance challenging nature of sublineage analysis. This study aimed to evaluate the feasibility of detecting HPV sublineages from 14 HPV genotypes in SurePath LBC samples from Danish cervical cancer screening. We included 41 HPV plasmids (the Global HPV LabNet DNA Genotyping Proficiency Panel 2023) to quality assure the NGS approach and 120 SurePath LBC samples from the screening program for proof of concept. Our results of the HPV plasmids showed the correct sublineage for all included HPV genotypes except for HPV68b, where the coverage was inadequate for sublineage analysis. The NGS analysis enabled HPV sublineage analysis in 99.1% (112/113) of HPV‐positive SurePath LBC samples. Sublineages belonging to the A lineage were most frequent for HPV16, 18, 31, 33, 35, 39, 51, 52, 58, 59, and 68, while B‐type sublineages showed the highest frequency in HPV45, 56, and 66. The most diverse sublineage data was obtained for HPV31 with sublineages from the A, B, and C lineages. In conclusion, our method enables the identification of HPV sublineages in SurePath LBC screening samples. This information can be used in future studies to determine the usefulness of HPV sublineage analysis in screening settings for risk stratification and clinical management of HPV‐positive women.

Trends in cervical cancer incidence in the Netherlands: A join‐point and age–period–cohort analysis (1989–2023)

Abstract Cervical cancer remains a significant public health issue, ranking as the fourth most common cancer in women globally. In the Netherlands, cervical cancer incidence declined steadily from 1989 to 2001 but increased between 2001 and 2007. This study updates trends in cervical cancer incidence from 1989 to 2023 in the Netherlands and evaluates the impact of screening practices and participation rates in the national population‐based screening program. This ecological study uses group‐level data from the Netherlands Cancer Registry (1989–2023) to analyze trends across three temporal dimensions—age, period, and cohort—using age–period–cohort analysis and join‐point regression to identify significant changes in trends over time. Cervical cancer incidence declined steadily from 1989 to 2003 but increased from 2003 to 2023, particularly among younger birth cohorts (1976–1995). This increase aligns with the decline in screening participation, which dropped from over 77% before 2003 to below 60% in subsequent years, as well as the introduction of primary high‐risk human papillomavirus testing in 2017, which has higher sensitivity than cytology, leading to more cases being detected and, consequently, an increase in incidence. Trends in cervical cancer incidence in the Netherlands indicate a positive impact of the screening program, with a steady decline over the years. However, efforts should focus on increasing participation in both screening and vaccination, as this is crucial for achieving the goal of reducing incidence to below 4 per 100,000 women, in line with the global strategy to eliminate cervical cancer.

p16INK4a and HPV E4 immunohistochemistry for the prediction of regression of cervical intraepithelial neoplasia grade 2—A historical cohort study

AbstractCervical intraepithelial neoplasia grade 2 (CIN2) is a heterogeneous diagnosis with a high likelihood of spontaneous regression. Therefore, active surveillance for CIN2 has been implemented as an option in younger women in many countries. Yet, little is known about markers that may accurately predict the likelihood of regression to support active surveillance. Here, we aimed to assess whether p16INK4a and HPV E4 status are associated with the likelihood of CIN2 regression. We conducted a historical cohort study on women aged 23–40 diagnosed with untreated CIN2 following cytology‐based screening. Women were diagnosed at Aarhus University Hospital, Denmark from January 2000 to December 2010. Archived tissue samples were sectioned for p16INK4a and HPV E4 immunohistochemistry and HPV genotyping. We used a modified Poisson model to estimate the relative risk of regression, adjusting for age and cytology (aRR). A total of 443 women with CIN2 were included. Most women (73.8%) were aged ≤30, and half had a high‐grade cytology (48.8%). Overall, 47.6% regressed, and regression was less likely in p16INK4a‐positive compared to p16INK4a‐negative women (aRR 0.77; 95% CI 0.64–0.94). Among p16INK4a‐positive women, the risk of regression varied by HPV type and HPVE4 status, with lower risk in HPV16‐positive women compared to those without (aRR 0.54; 95% CI 0.40–0.75) and in HPVE4‐negative compared to HPVE4 positive women (aRR 0.73; 95% CI 0.54–0.98). When we restricted to expert‐confirmed CIN2, the risk of regression did not vary by p16INK4a or HPVE4 status, while HPV16 positive remained at a lower risk of regression compared to women without HPV16.

Whole‐genome sequencing of 1,083 HPV45 cases and controls identifies genetic variants associated with glandular cervical lesions

AbstractHuman papillomavirus type 45 (HPV45) causes ~6% of all cervical cancers and an even greater proportion of adenocarcinomas, the latter of which are challenging to detect using current cervical cancer screening. Little is known about how HPV45 genetic variation is related to the risk of cervical precancer/cancer. To investigate this, we whole‐genome sequenced a total of 1,083 HPV45‐positive samples from two large studies. We evaluated associations of HPV45 genetic variation (sublineages, subclades, and SNPs) with histology‐specific precancer/cancer risk using logistic regression and evaluated risk modification by self‐reported race/ethnicity. Compared to the common A1 sublineage, A2 and B1 were associated with increased precancer/cancer (A2, OR = 3.9, 95% CI = 1.9–8.5; B1, OR = 2.7, 95% CI = 1.3–5.8; B2, OR = 3.3, 95% CI = 1.6–7.3), and most strongly with the glandular precancers/cancers (AIS/ADC; A2, OR = 6.9, 95% CI = 1.0–184; B1, OR = 6.2, 95% CI = 1.1–159). The A2 sublineage was most prevalent in women in East Asia and women who self‐reported as Asian/Pacific Islander (PI) in the U.S.; East Asian and Asian/PI women had the greatest precancer/cancer risk associated with A2 infections (OR = 5.8, 95% CI = 1.3–37.4) compared to all other sublineages among these women. We further evaluated precancer/cancer risk associations for 262 individual HPV45 SNPs and identified four SNPs significantly associated with only glandular precancers/cancers after correction for multiple tests (ORs ranged 7.8–20.7). One of these SNPs was a nonsynonymous variant in both overlapping viral E2/E4 ORFs. In summary, we show that HPV45 genetic variation influences the risk of precancer/cancer, specifically glandular precancer/cancer. Further studies of these genetic variants may improve our understanding of glandular lesions.

Colposcopy referrals and CIN3 detection after triage by host cell DNA methylation and/or HPV genotyping in HPV positive women with low‐grade cytology from a population‐based Dutch primary HPV screening trial

AbstractHigh‐risk HPV (hrHPV)‐based screening has led to many unnecessary colposcopy referrals, mainly because of direct referral after low‐grade cytology (ASC‐US/LSIL). DNA methylation and genotyping tests on ASC‐US/LSIL samples have the potential to significantly improve the efficiency of screening. In this study, 12 triage strategies were constructed from FAM19A4/miR124‐2 or ASCL1/LHX8 methylation, HPV16/18 or HPV16/18/31/33/45 genotyping and 1‐year repeat cytology. The performance was evaluated on 215 hrHPV‐positive ASC‐US/LSIL samples from the IMPROVE trial (NTR5078). Performance was measured by colposcopy referral rate, positive predictive value (PPV) for detecting precancer (CIN3), and negative predictive value (NPV). To evaluate efficiency, strategies were ordered by the cumulative colposcopy referral rate after 1‐year cytology and compared by the marginal PPV to detect one additional CIN3 (mPPV). The most conservative strategy (referral when HPV16/18 and FAM19A4/miR124 methylation results are positive) had a direct referral rate of 5.2%, a cumulative referral rate after 1‐year cytology of 54.1%, and mPPV of 19.3%. Replacing HPV16/18 by HPV16/18/31/33/45 increased the cumulative 1‐year referral rate to 54.6%, and yielded an mPPV of 10.0%. Similar results were obtained for strategies with ASCL1/LHX8 methylation. Of all strategies, referral after an HPV16/18/31/33/45 positive, ASCL1/LHX8 methylation‐positive, and/or 1‐year cytology‐positive result yielded the highest direct and cumulative 1‐year colposcopy referral rates of 64.4% and 79.1%, respectively. The NPVs after 1‐year cytology varied between 98.1% and 99.4%, warranting a return to routine screening. Altogether, DNA methylation‐based triage strategies are recommended as they are discriminative for CIN3 and control the number of immediate colposcopy referrals.

Technical, legal and ethical framework of cancer audit in cervical screening – Summary of best practices for organised programmes delineated through an expert group consultation

AbstractEfficient and well‐organised cervical screening programmes have significantly reduced both the incidence and mortality rates of cervical cancer in the population. For optimal performance, such programmes need to incorporate essential quality assurance measures. The International Agency for Research on Cancer (IARC/WHO) organised an expert consultation to delineate best practices in auditing cancers in a cervical screening programme, the legal and ethical frameworks governing such audits, and communicating audit outcomes. As a best practice, every programme should have a well‐documented policy and process framework for cancer audits. The TWGs agreed that the primary goal of programmatic cancer audits is to assess the programme's effectiveness in lowering cervical cancer incidence and minimising screening‐related risks. Using audit results, informed decisions can be made to enhance service delivery, including professional training, adopting improved screening tests, strengthening fail‐safe mechanisms, reducing delays, and minimising inequalities. Legal complexities in cervical screening stem from its inherent limitations and risks, and differentiating cases of negligence from inevitable and non‐negligent errors where an abnormality is not detected but actually exists is crucial. TWGs suggested that determining whether a screening error was serious enough to be categorised as negligent and/or to entitle the patient to compensation should reflect the inherent limitations of cervical screening. Data obtained while performing screening tests and subsequent diagnostic tests or treatments are sensitive and need to be safeguarded. The best practice document drafted through expert consultation will help cervical screening programmes standardise practices related to cancer audits and address associated legal and ethical issues.

DNA methylation signatures of cervical pre‐invasive and invasive disease: An epigenome‐wide association study

AbstractEpigenetic alterations are essential in the development of cancers, while epigenome‐wide exploration in cervical cancer has been limited. In this epigenome‐wide association study (EWAS) we explore differential DNA methylation signatures associated with CIN (cervical intraepithelial neoplasia) grade 3 and cervical cancer to better understand potential drivers and biomarkers of cervical carcinogenesis. 247 women were recruited between 2014 and 2020 (N = 119 benign, N = 74 CIN3/CGIN [cervical glandular intraepithelial neoplasia] and N = 54 cancer). Methylation signatures were obtained from exfoliated cervical cells and sequenced using the Illumina 850 k array. Logistic regression and conditional analyses were used to test for independent associations between Cytosine‐phosphate‐Guanine (CpG) sites and case–control status, with adjustment for batch, chip, age, and human papillomavirus (HPV) status. 409 CpG sites were strongly associated with CIN3/cancer (p‐value <5 × 10−8). Following conditional analysis, two CpG sites located in PAX1 (cg16767801) and NREP‐AS1 genes (cg23642047) were independently associated with case status, yielding an area under the curve (AUC) of 0.92 (AUC = 0.97 for invasive disease). In a validation dataset (CIN3 only) PAX1/NREP‐AS1 yielded a combined AUC of 0.77. Methylation markers offer promise for use in cervical screening, particularly as triage tests and self‐sampling. We have identified a novel combined methylation marker that offers a high accuracy for the detection of CIN3 or worse.

Risk of high‐grade cervical lesions in the second round of primary human papillomavirus testing in CervicalScreen Norway: A population‐based cohort study

AbstractAs many countries are transitioning from cytology to human papillomavirus (HPV) testing as the primary cervical cancer screening test, we evaluated the impact of cumulative HPV screening during the implementation of HPV screening in the Norwegian cervical cancer screening programme (CervicalScreen Norway). Data from the second HPV screening round was compared with data from the first round. The second‐round analyses included only women who returned to routine screening 4–6 years following a negative HPV test in the first round. Associations between screening rounds and HPV positivity, cytology results, and follow‐up recommendations were estimated by multinomial logistic regression, and relative risks of cervical intraepithelial neoplasia, grade 3 or worse (CIN3+) by Cox regression. There was a 42% lower risk of being HPV positive in the second screening round compared to the first (age‐adjusted relative risk ratio (aRRR) 0.58, 95% confidence interval (CI) 0.53 to 0.65), and a 70% lower risk of having high‐grade cytology among HPV16 positive women (0.30, 0.12 to 0.78). There was also a 51% reduction in referrals for immediate colposcopy (0.49, 0.39 to 0.62). The overall risk of CIN3+ was 71% lower in the second round compared to the first (age‐adjusted hazard ratio [aHR] 0.29, 95%CI 0.21–0.40), and lower among HPV16 and other high‐risk HPV positive women, but not among HPV18 positives. No cervical cancers were diagnosed in the second round (mean follow‐up 2.4 years). Our findings indicate that HPV test results from previous screening rounds should be considered when designing optimal screening algorithms.

Cervical cancer incidence rates considering migration status in mainland China using Bayesian model—Estimation based on 2016 cancer registry data

AbstractIn mainland China, cancer registration relies on household‐registered populations, overlooking migrant populations. Estimating cervical cancer incidence among permanent residents, including migrants, offers a more accurate representation of the true burden. The data from 487 cancer registries across China in 2016 were analyzed using a Bayesian spatial regression model with the integrated nested Laplace approximation‐stochastic partial differential equation method. The study estimated cervical cancer incidence among household‐registered populations and adjusted for migrant populations using a weighting method based on interprovincial distribution and age stratification to derive the incidence of cervical cancer in the permanent residents. Data from the China Population Census, the China Migrants Dynamic Survey, and the Urban Statistical Yearbook were incorporated. The estimated crude incidence rate of cervical cancer among permanent residents was 17.4/100,000 in mainland China, with an age‐standardized incidence rate (ASIR) of 17.2/100,000. The largest disparities in cervical cancer crude incidence rate between permanent residents and household‐registered populations were observed in Guizhou (2.4/100,000, 95% CI 1.9–2.9/100,000), Zhejiang (−1.2/100,000, 95% CI −1.8 to −0.6/100,000) and Tianjin (−1.1/100,000, 95% CI −1.5 to −0.7/100,000). The number of the estimated cervical cancer incident cases was 8948. Guangdong saw an increase of 887 cases, while Henan had a decrease of 1430 cases. Guizhou had the highest ASIR (28.1/100,000), and Beijing had the lowest ASIR (11.0/100,000). The significance of this study is that it improves the accuracy of cervical cancer data in China. These findings provide evidence for developing cervical cancer prevention and control strategies, and offer insights for other countries and regions facing migration challenges.

Participation and relative cost of attendance by direct‐mail compared to opt‐in invitation strategy for HPV self‐sampling targeting cervical screening non‐attenders: A large‐scale, randomized, pragmatic study

AbstractBroad accessibility to cervical cancer screening and high participation rate is essential to reduce cervical cancer incidence. HPV self‐sampling is an alternative to clinician collected cervical samples to increase accessibility and screening coverage. To inform on deployment strategies of HPV self‐sampling, this large‐scale, randomized, pragmatic study compared two invitation modalities; direct‐mail and opt‐in. The study included screening non‐attenders from the Capital Region of Denmark randomly allocated (1:4) to a direct‐mail or opt‐in invitation for cervical screening by HPV self‐sampling. Primary endpoint was screening participation; secondary endpoints were HPV prevalence and histology outcome. Adherence to follow‐up and cost were also evaluated. After exclusion of hysterectomized/non‐accessible women, 49,393 women were invited: 9639 by direct‐mail, and 39,754 by the opt‐in offer. A direct‐mail invitation for HPV self‐sampling yielded a significant higher participation than an opt‐in invitation. HPV self‐sample participation for direct‐mail was 25.2% (n = 2426), opt‐in participation was 20.2% (n = 8047), adjusted OR = 1.27, 95% CI 1.20–1.34. Participation increased with age (p < .0001) for both strategies and decreased with screening history of non‐attendance (p < .0001). Interaction between invitation strategy and age/screening history was found; more women below 50 years of age participated by direct‐mail compared to opt‐in (p < .0001) and higher participation by direct‐mail group was found in women with a short history of non‐attendance (p < .0001). Participation of long‐term unscreened women was similar between arms. The relative cost was ≈14 HPV self‐sample kits distributed per additional participant by direct‐mail over opt‐in. HPV prevalence, adherence to follow‐up, and detection of high‐grade cervical intraepithelial neoplasia was similar between invitation strategies.

Nationwide cohort study on the risk of high‐grade cervical dysplasia and carcinoma after conservative treatment or hysterectomy for adenocarcinoma in situ

AbstractInternationally, little consensus exists about the best treatment for cervical adenocarcinoma in situ (AIS). This study aimed to determine the incidence of recurrent high‐grade cervical dysplasia and development of local cervical cancer after treatment for AIS. This nationwide, retrospective cohort study included patients with AIS, who were treated by a large loop excision of the transformation zone (LLETZ), cold‐knife conization (CKC), or hysterectomy between January 1, 1990 and December 31, 2021 in the Netherlands. Pathology reports were retrieved from the Dutch Nationwide Pathology Databank (Palga). Primary outcomes were the cumulative incidences of high‐grade cervical dysplasia (cervical intraepithelial neoplasia grade 2 or 3, and AIS) and local cervical cancer up to 20 years after primary treatment. In total, 4243 patients with AIS were included. The primary treatment was a LLETZ, CKC, or hysterectomy in 1593, 2118, and 532 patients, respectively. The incidence of recurrent high‐grade cervical dysplasia after LLETZ (10.5%; 95%CI: 8.6–12.3) was higher than after CKC (5.5%; 95%CI: 4.4–6.6, p <.0001). When a radical excision, that is, surgical margins free of dysplasia at end of treatment, was achieved, the incidence of recurrent high‐grade dysplasia and local cervical cancer did not differ between LLETZ (5.6% [95%CI: 3.3–7.9] and 1.9% [95%CI: 0–4.4]) and CKC (4.7% [95%CI: 3.5–5.8], p = .631 and 1.5% [95%CI: 0.7–2.3], p = .918). After hysterectomy, none of the patients developed cervical dysplasia or local cervical cancer. Conservative treatment for AIS can be considered a safe and final treatment modality when a radical excision is achieved.

Acceptability and validity of HPV self‐sampling for cervical cancer screening among women living in different ecological settings in India

AbstractIndia records one fifth of global cervical cancer burden. Unlike human papillomavirus (HPV) self‐sampling, other screening methods may cause discomfort and embarrassment. This study aimed to investigate attitudes, acceptability, barriers, predictors, effective modality of instructions, and validity of HPV self‐sampling among Indian women residing in varied settings and different literacy levels. This is community‐based interventional study among Indian women 30–55 years, residing in urban slums (500), urban non‐slums (500), and rural (600) settings with varied washroom facilities and privacy, to collect self‐samples. Each group was subdivided into two arms; in one women received education with pamphlets and other with health education program (HEP). Study involved enlisting eligibles, obtaining informed consents and conducting personal interviews to collect baseline data. Self‐samplers were distributed with instructions (pictorial pamphlets in one group and HEP in other) regarding usage, storage and return. Willingness to use self‐samplers, refusals, experiences, and so forth were captured. Post‐intervention knowledge, attitudes, practices was recorded. HPV reports were distributed. Women with positive result on either test were offered further management. Acceptance rate of self‐sampling was 99.2%, 97%, and 98.8% and HPV positivity was 7%, 7.8%, and 8.5%, respectively among urban non‐slum, urban slum and rural women. Agreement rate between health personnel collected and self‐collected samples was 96.5% in pamphlet and 93.2% in HEP arm. Major barriers of self‐sampling were lack of confidence about performing self‐test correctly, fear that test would be painful and anxiety about test results. HPV self‐sampling has good acceptability among Indian women and good agreement with health personnel collected samples.

Clinically validated HPV assays offer comparable long‐term safety in primary cervical cancer screening: A 9‐year follow‐up of a population‐based screening cohort

AbstractMolecular testing for human papillomaviruses (HPV) is gradually replacing cytology in cervical cancer screening. In this longitudinal population‐based cohort study, 4140 women 20 to 64 years old attending organized screening were tested at baseline by five different screening methods and followed for 9 years. To assess long‐term safety, the cumulative risks of CIN2+/CIN3+ were estimated after a negative baseline result obtained by conventional cytology and four clinically validated HPV assays: Hybrid Capture 2 (hc2), RealTime High Risk HPV assay (RealTime), cobas 4800 HPV Test (cobas_4800), and Alinity m HR HPV (Alinity). HPV‐negative women at baseline had a substantially lower risk for CIN2+ compared to those with normal baseline cytology: 0.84% (95% CI, 0.46–1.22), 0.90% (95% CI, 0.51–1.29), 0.78% (95% CI, 0.42–1.15), and 0.75% (95% CI, 0.39–1.11) for hc2, RealTime, cobas_4800, and Alinity, respectively, compared to 2.46% (95% CI, 1.88–3.03) for cytology. No differences were observed between HPV assays in longitudinal sensitivity (range: 86.21%–90.36%) and negative predictive values (range: 99.54%–99.70%) for CIN2+ in women ≥30 years, but were significantly different from cytology (p < .05). The 9‐year cumulative risk of CIN2+ differed significantly between HPV genotypes, reaching 32.1% (95% CI, 14.5–46.1) for HPV16, 24.9% (95% CI, 4.7–40.8) for HPV18/45, 27.2% (95% CI, 14.6–37.8) for HPV31/33/35/52/58, and 8.1% (95% CI, 0.0–16.7) for HPV39/51/56/59. Four clinically validated HPV assays showed comparable safety and better assurance against precancerous lesions than cytology, but some important differences were identified in the performance characteristics of HPV assays impacting the referral rate. Information about the HPV genotype is valuable for guiding further clinical action in HPV‐based screening programs.

A new treatment approach of toripalimab in combination with concurrent platinum‐based chemoradiotherapy for locally advanced cervical cancer: A phase II clinical trial

AbstractThis study investigated the efficacy and safety of toripalimab in combination with concurrent platinum‐based chemoradiation in patients with untreated locally advanced cervical cancer. Eligible patients received toripalimab 240 mg once every 3 weeks in combination with concurrent platinum‐based chemoradiotherapy, followed by the maintenance of toripalimab once every 6 weeks up to 1 year. The primary endpoint was objective response rate (ORR). Secondary endpoints included 2‐year and 3‐year progression‐free survival (PFS) rates, 3‐year overall survival (OS) rate, and safety. Biomarker analysis of PD‐L1 expression and genomic mutational analysis by next‐generation sequencing were conducted, as well as PD‐L1 expression on tumor biopsies. A total of 82 patients were enrolled. The median follow‐up was 21 months (range, 5.2–44.5 months). The ORR and disease control rate were both 87.8% among the 82 patients. Median PFS and OS were not reached. A trend toward longer PFS was observed in the populations with a PD‐L1 combined positive score ≥10, low tumor mutation burden and loss of heterozygosity in human leukocyte antigen (HLA LOH) detected populations. A total of 37 patients experienced treatment‐related adverse events, of which 17 (20.7%) patients experienced grade 3 or higher adverse events. Collectively, toripalimab plus concurrent platinum‐based chemoradiotherapy showed promising antitumor efficacy with acceptable safety profiles in patients with untreated locally advanced cervical cancer.

Performance of visual inspection, partial genotyping, and their combination for the triage of women living with HIV who are screen positive for human papillomavirus: Results from the AIMA‐CC ANRS 12375 multicentric screening study

AbstractThe WHO recommends the use of human papillomavirus (HPV) testing for primary cervical cancer (CC) screening because of its high sensitivity. However, triage is desirable to correctly identify HPV+ women who have high‐grade lesions (CIN2+) and require treatment. The ANRS‐12375 study was conducted in Côte d'Ivoire, Burkina Faso and Cambodia to assess the performance, feasibility and benefits of different triage options for detecting CIN2+ lesions: partial (HPV16 and HPV16/18/45) and extended genotyping, visual inspection (VIA) alone and VIA combined with partial genotyping. VIA was performed by gynecologists. The sensitivity, specificity, and diagnostic likelihood ratio (DLR) of each triage option for detecting CIN2+ lesions with histology as a reference standard were calculated. Of the 2253 women living with HIV (WLHIV) included, 932 (41%) were HPV+. A CIN2+ lesion was identified in 105 (13%) of the 777 participants with histopathology results. The sensitivity of VIA as a triage test for CIN2+ patients was 89%, while that for extended genotyping was 89%, that for HPV16/18/45 partial genotyping was 51%, and that for HPV16 partial genotyping was 36%. The specificities for these tests were 45%, 29%, 72%., and 85%, respectively. Combining VIA and/or partial genotyping positivity slightly increased the sensitivity (94%) at the cost of lower specificity (28%). There was significant intersite heterogeneity (p = .04). Among the three triage tests with a sensitivity ≥85%, the VIA had the highest specificity and positive likelihood ratio (p < .001). VIA and extended genotyping, whether independent or combined, are good triage options with high sensitivity for identifying WLHIV needing treatment for CIN2+.

Sociodemographic characteristics associated with cervical cancer screening participation by send‐to‐all and opt‐in HPV self‐sampling: Who benefits? Results from a randomized controlled trial among long‐term non‐attending women in Norway

AbstractWith the objective to investigate associations between sociodemographic characteristics and participation in interventions designed to increase participation in cervical cancer screening among under‐screened women, we randomized a random sample of 6000 women in Norway aged 35–69 years who had not attended cervical screening for ≥10 years to receive either (i) a reminder to attend regular screening (control), (ii) an offer to order a self‐sampling kit (opt‐in), or (iii) a self‐sampling kit unsolicited (send‐to‐all). We analyzed how sociodemographic characteristics were associated with screening participation within and between screening arms. In the send‐to‐all arm, increased screening participation ranged from 17.1% (95% confidence interval [95% CI] = 10.3% to 23.8%) to 30.0% (95% CI = 21.5% to 38.6%) between sociodemographic groups. In the opt‐in arm, we observed smaller, and at times, non‐significant increases within the range 0.7% (95% CI = −5.8% to 7.3%) to 19.1% (95% CI = 11.6% to 26.7%). In send‐to‐all versus control comparisons, there was greater increase in participation for women in the workforce versus not (6.1%, 95% CI = 1.6% to 10.6%), with higher versus lower income (7.6%, 95% CI = 2.2% to 13.1%), and with university versus primary education (8.5%, 95% CI = 2.4% to 14.6%). In opt‐in versus control comparisons, there was greater increase in participation for women in the workforce versus not (4.6%, 95% CI = 0.7% to 8.5%), with higher versus lower income (6.3%, 95% CI = 1.5% to 11.1%), but lower increase for Eastern European versus Norwegian background (−12.7%, 95% CI = −19.7% to −5.7%). Self‐sampling increased cervical screening participation across all sociodemographic levels, but inequalities in participation should be considered when introducing self‐sampling, especially with the goal to reach long‐term non‐attending women.

Recurrent cervical cancer detection using DNA methylation markers in self‐collected samples from home

AbstractEarly detection of recurrent cervical cancer is important to improve survival rates. The aim of this study was to explore the clinical performance of DNA methylation markers and high‐risk human papillomavirus (HPV) in cervicovaginal self‐samples and urine for the detection of recurrent cervical cancer. Cervical cancer patients without recurrence (n = 47) collected cervicovaginal self‐samples and urine pre‐ and posttreatment. Additionally, 20 patients with recurrent cervical cancer collected cervicovaginal self‐samples and urine at time of recurrence. All samples were self‐collected at home and tested for DNA methylation and high‐risk HPV DNA by PCR. In patients without recurrent cervical cancer, DNA methylation levels decreased 2‐years posttreatment compared to pretreatment in cervicovaginal self‐samples (p < .0001) and urine (p < .0001). DNA methylation positivity in cervicovaginal self‐samples was more frequently observed in patients with recurrence (77.8%) than in patients without recurrence 2‐years posttreatment (25.5%; p = .0004). Also in urine, DNA methylation positivity was more frequently observed in patients with recurrence (65%) compared to those without recurrence (35.6%; p = .038). Similarly, high‐risk HPV positivity in both cervicovaginal self‐samples and urine was more frequent (52.6% and 55%, respectively) in patients with recurrence compared to patients without recurrence (14.9% and 8.5%, respectively) (p = .004 and p = .0001). In conclusion, this study shows the potential of posttreatment monitoring of cervical cancer patients for recurrence by DNA methylation and high‐risk HPV testing in cervicovaginal and urine samples collected at home. The highest recurrence detection rate was achieved by DNA methylation testing in cervicovaginal self‐samples, detecting 77.8% of all recurrences and, specifically, 100% of the local recurrences.

Nationwide registry‐based trial of risk‐stratified cervical screening

AbstractIn well‐screened populations, most cervical cancers arise from small groups of women with inadequate screening. The present study aims to assess whether registry‐based cancer risk assessment could be used to increase screening intensity among high‐risk women. The National Cervical Screening Registry identified the 28,689 women residents in Sweden who had either no previous cervical screening or a screening history indicating high risk. We invited these women by SMS and/or physical letter to order a free human papillomavirus (HPV) self‐sampling kit. The Swedish national HPV reference laboratory performed extended HPV genotyping and referred high‐risk HPV‐positive women to their regional gynecologist. A total of 3691/28,689 (12.9%) women ordered a self‐sampling kit and 10.0% (2853/28,689) returned a sample for testing. Participation among women who had never attended screening was low, albeit improved. Up to 22.5% of women in other high‐risk groups attended. High‐risk HPV types were detected in 8.3% of samples. High‐risk HPV‐positive women (238/2853) were referred without further triaging and severe cervical precancer or cancer (HSIL+) in histopathology were detected in 36/158 (23%) of biopsied women. Repeat invitations gave modest additional participation. Nationwide contacting of women with high risk for cervical cancer with personal invitations to order HPV self‐sampling kits resulted in high yield of detected CIN2+. Further efforts to improve risk‐stratified screening strategies should be directed to improving (i) the precision of the risk‐stratification algorithm, (ii) the convenience for the women to participate and, (iii) ensuring that screen‐positive women are followed‐up.

Plasma cell‐free DNA methylation analysis for ovarian cancer detection: Analysis of samples from a case‐control study and an ovarian cancer screening trial

AbstractAnalysis of cell‐free DNA methylation (cfDNAme), alone or combined with CA125, could help to detect ovarian cancers earlier and may reduce mortality. We assessed cfDNAme in regions of ZNF154, C2CD4D and WNT6 via targeted bisulfite sequencing in diagnostic and early detection (preceding diagnosis) settings. Diagnostic samples were obtained via prospective blood collection in cell‐free DNA tubes in a convenience series of patients with a pelvic mass. Early detection samples were matched case‐control samples derived from the UK Familial Ovarian Cancer Screening Study (UKFOCSS). In the diagnostic set (ncases = 27, ncontrols = 41), the specificity of cfDNAme was 97.6% (95% CI: 87.1%‐99.9%). High‐risk cancers were detected with a sensitivity of 80% (56.3%‐94.3%). Combination of cfDNAme and CA125 resulted in a sensitivity of 94.4% (72.7%‐99.9%) for high‐risk cancers. Despite technical issues in the early detection set (ncases = 29, ncontrols = 29), the specificity of cfDNAme was 100% (88.1%‐100.0%). We detected 27.3% (6.0%‐61.0%) of high‐risk cases with relatively lower genomic DNA (gDNA) contamination. The sensitivity rose to 33.3% (7.5%‐70.1%) in samples taken <1 year before diagnosis. We detected ovarian cancer in several patients up to 1 year before diagnosis despite technical limitations associated with archival samples (UKFOCSS). Combined cfDNAme and CA125 assessment may improve ovarian cancer screening in high‐risk populations, but future large‐scale prospective studies will be required to validate current findings.

The influence of birth cohort and calendar period on global trends in ovarian cancer incidence

Ovarian cancer is the eighth most common cancer in women worldwide and incidence rates vary markedly by world region. Our study provides a comprehensive overview of ovarian cancer incidence trends globally, examining the influence of birth cohort and period of diagnosis on changing risk. We presented current patterns and trends of ovarian cancer incidence until 2012 using data from successive volumes of Cancer Incidence in Five Contents. The incidence of ovarian cancer is highest in northern and eastern European countries and in northern America. Declining trends were observed in most countries with the exception of a few central and eastern Asian countries. Marked declines were seen in Europe and North America for women aged 50–74 where rates have declined up to 2.4% (95% CI: −3.9, −0.9) annually in Denmark (DNK) over the last decade. Additionally, declines in the incidence rate ratio (IRR) were observed for generations born after the 1930s, with an additional strong period effect seen around 2000 in United States and DNK. In contrast, IRRs increased among younger generations born after the 1950s in Japan and Belarus. Overall, the favorable trends in ovarian cancer incidence is likely due to the increase use of oral contraceptive pills, and changes in the prevalence of other reproductive risk and protective factors for ovarian cancer over the years studied. Changes in disease classifications and cancer registry practices may also partially contribute to the variation in ovarian cancer incidence rates. Thus, continuous cancer surveillance is essential to detect the shifting patterns of ovarian cancer.

Thirteen cancers associated with HIV infection in a Black South African cancer patient population (1995‐2016)

AbstractSouth Africa's HIV epidemic has evolved over time in terms of numbers of people living with HIV, access to antiretroviral treatment (ART) and age. These changes have profoundly influenced local cancer patterns. The Johannesburg Cancer Study has, over a period of 22 years (1995‐2016), recruited over 20 000 incident black cancer patients who consented to provide answers to a questionnaire and blood samples (serum, DNA). This has presented a unique opportunity to examine the evolving association of HIV with cancer in Africa. We used logistic regression models to explore case‐control associations between specific cancers and HIV, using participants with non‐infection related cancers as controls. Using data of 20 835 cancer patients with confirmed HIV status, we found the following cancers to be associated with HIV: Kaposi's sarcoma (ORadj; 95%CI): (99.1;72.6‐135.1), non‐Hodgkin lymphoma (11.3;9.3‐13.6), cervical cancer (2.7;2.4‐3.0), Hodgkin lymphoma (3.1;2.4‐4.2), cancer of the eye/conjunctiva (18.7;10.1‐34.7), anogenital cancers (anus [2.1;1.4‐3.2], penis [5.4;2.7‐10.5], vulva [4.8;3.5‐6.4], vagina [5.5;3.0‐10.2]), oropharyngeal cancer (1.6;1.3‐1.9), squamous cell carcinoma of the skin (3.5;2.4‐4.9), melanoma (2.0;1.2‐3.5) and cancer of the larynx (1.7;1.3‐2.4). Kaposi's sarcoma odds ratios increased from the pre‐ART (1995‐2004) to the early ART (2005‐2009) period but declined in the late ART (2010‐2016) period. Odds ratios for cancers of the eye/conjunctiva, cervix, penis and vulva continued to increase in recent ART periods. Our study confirms the spectrum of HIV‐associated cancers found in other African settings. The odds ratios of conjunctival and HPV‐related cancers continue to rise in the ART era as the HIV positive population ages.

Molecular profiles of BRCA1‐associated ovarian cancer treated by platinum‐based therapy: Analysis of primary, residual and relapsed tumors

Our study aimed to analyze the evolution of molecular portraits of BRCA1‐driven ovarian cancer (OC) during treatment. BRCA1 loss‐of‐heterozygosity status (LOH) and exome profiles were investigated in serial OC samples from 13 patients, which included primary tumors (n = 11) obtained before neoadjuvant therapy (NACT) or at primary debulking surgery, residual post‐NACT cancer tissues (n = 13) and tumor relapses (16 samples from 13 patients). Loss of the wild‐type BRCA1 allele was detected in 11/11 (100%) primary tumors, 6/13 (46%) residual post‐NACT OC samples and 15/16 (94%) OC relapses. Full tumor triplets were available for four patients undergoing NACT; whereas primary carcinomas from these patients demonstrated BRCA1 LOH, the retention of the wild‐type allele was detected in all four post‐NACT residual tumors. These four women provided to the study 5 recurrent OC samples; 4 out of 5 tumor relapses had BRCA1 LOH thus resembling BRCA1 status observed in primary but not residual OC tissues. TP53 mutation was detected in 12 out of 13 patients and was retained across all serial samples. OC relapses tended to acquire additional intragenic mutations in genes involved in cell migration, adhesion and cell junction assembly. BRCA1‐driven OCs demonstrate the plasticity of BRCA1 status during the treatment course. NACT results in rapid selection of pre‐existing BRCA1‐proficient cells. However, BRCA1 proficiency appears to be disadvantageous in the absence of platinum exposure, as tumor relapses usually re‐acquire BRCA1 LOH during therapy holidays.

Prediagnosis and postdiagnosis smoking and survival following diagnosis with ovarian cancer

Little is known about the influence of prediagnosis and postdiagnosis smoking and smoking cessation on ovarian cancer survival. We investigated this relationship in two prospective cohort studies, the Nurses’ Health Study (NHS) and NHSII. Analyses included 1,279 women with confirmed invasive, Stage I–III epithelial ovarian cancer. We used Cox proportional hazards regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for ovarian cancer‐specific mortality by smoking status, adjusting for age and year of diagnosis, tumor stage, histologic subtype, body mass index and nonsteroidal anti‐inflammatory use (postdiagnosis models only). When examining prediagnosis smoking status (assessed a median of 12 months before diagnosis), risk of death was significantly increased for former smokers (HR = 1.19, 95% CI: 1.02–1.39), and suggestively for current smokers (HR = 1.21, 95% CI: 0.96–1.51) vs. never smokers. Longer smoking duration (≥20 years vs. never, HR = 1.23, 95% CI: 1.05–1.45) and higher pack‐years (≥20 pack‐years vs. never, HR = 1.28, 95% CI: 1.07–1.52) were also associated with worse outcome. With respect to postdiagnosis exposure, women who smoked ≥15 cigarettes per day after diagnosis (assessed a median of 11 months after diagnosis) had increased mortality compared to never smokers (HR = 2.34, 95% CI: 1.63–3.37). Those who continued smoking after diagnosis had 40% higher mortality (HR = 1.40, 95% CI: 1.05–1.87) compared to never smokers. Overall, our results suggest both prediagnosis and postdiagnosis smoking are associated with worse ovarian cancer outcomes.

Long noncoding RNA TC0101441 induces epithelial–mesenchymal transition in epithelial ovarian cancer metastasis by downregulating KiSS1

Peritoneal metastasis is a critical feature and clinical challenge in epithelial ovarian cancer (EOC). We previously identified a novel long noncoding RNA (lncRNA, TC0101441) in epithelial ovarian cancer (EOC) using microarrays. However, the impact of TC0101441 on EOC metastasis and prognosis remains unclear. TC0101441 expression in EOC tissues and its correlation with clinicopathological factors and prognosis were examined. A series of in vitro and in vivo assays were performed to elucidate the roles and mechanism of TC0101441 in EOC metastasis. We found that TC0101441 levels were elevated in EOC tissues compared with those in normal controls and significantly correlated with an advanced clinical stage and lymph node metastasis. TC0101441 was determined to be an independent prognostic predictor of overall survival (OS) and disease‐free survival (DFS). Furthermore, loss‐of‐function assays showed that TC0101441 promoted the invasive and metastatic capacities of EOC cells both in vitro and in vivo. Mechanistically, the prometastatic effects of TC0101441 were linked to the induction of epithelial–mesenchymal transition (EMT). Importantly, KiSS1 was identified as a downstream target gene of TC0101441 and was downregulated by TC0101441 in EOC cells. After TC0101441 was silenced, the corresponding phenotypes of EOC cell invasion and EMT were reversed by the overexpression of KiSS1. Taken together, our data suggest that TC0101441 functions as a potential promigratory/invasive oncogene by promoting EMT and metastasis in EOC through downregulation of KiSS1, which may represent a novel prognostic marker and therapeutic target in EOC.

Menopausal hormone therapy treatment options and ovarian cancer risk: A Swedish prospective population‐based matched‐cohort study

Although menopausal hormone therapy (MHT) seemingly increases the risk of ovarian cancer, evidence is insufficient whether the risk varies between various MHT formulations, regimens and administration modes. With the aim of filling these knowledge gaps, we investigated the effect of different MHT treatment options on the risk of ovarian cancer. This prospective Swedish population‐based matched‐cohort study included all women ≥40 years having used systemic MHT between 2005 and 2012 (288,950 ever‐users), group‐level matched (1:3) to 866,546 nonusers. MHT use was ascertained from the Swedish Prescribed Drug Registry and data was linked to several national health data registries. Multivariable conditional logistic regression provided odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for parity, and comorbidities. Current EP‐MHT use was associated with a modestly increased risk of ovarian cancer (OR = 1.38, 95% CI 1.18–1.62), while no consistent risk was found among past users (OR = 1.00, 95% CI 0.84–1.18). Current continuous testosterone derived (OR = 1.50, 95% CI 1.15–1.96) regimens increased the risk whereas progesterone derived (OR = 1.48, 95% CI 1.00–2.21) regimens increased the risk marginally. Nonsignificant positive associations were observed for sequential regimens (OR = 1.87, 95% CI 0.70–5.08; OR = 1.54, 95% CI 0.96–2.47, respectively). An inverse relationship was observed for all E‐MHT use (OR = 0.25, 95% CI 0.22–0.29), but this association might partly be explained by underreporting of oophorectomies or tubal ligations. Current cutaneous EP‐MHT (OR = 1.28, 95% CI 0.81–2.02) suggested a possibly lower risk than oral MHT (OR = 1.48, 95% CI 1.25–1.75). In conclusion EP‐MHT, notably continuous regimens, were associated with a modestly increased risk of ovarian cancer. The role of E‐MHT requires further clarification.

SMYD3 promotes implant metastasis of ovarian cancer via H3K4 trimethylation of integrin promoters

Detachment of cancer cells from the primary tumor and formation of spheroids in ascites is required for implantation metastasis in epithelial ovarian cancer (EOC), but the underlying mechanism of this process has not been thoroughly elucidated. To mimic this process, ovarian cancer cells were grown in 3D and 2D culture. Hey and OVCA433 spheroids exhibited decreased cell proliferation and enhanced adhesion and invasion. SMYD3 expression was elevated in ovarian carcinoma spheroids in association with increased H3K4 methylation. Depletion of SMYD3 by transient siRNA, stable shRNA knockdown and the SMYD3 inhibitor BCI‐121 all decreased spheroid invasion and adhesion. Gene expression arrays revealed downregulation of integrin family members. Inhibition assays confirmed that invasion and adhesion of spheroids are mediated by ITGB6 and ITGAM. SMYD3‐deficient cells regained the ability to invade and adhere after forced overexpression of SMYD3, ITGB6 and ITGAM. However, this biological ability was not restored by forced overexpression of SMYD3 in ITGB6‐ and/or ITGAM‐deficient cancer cells. SMYD3 and H3K4me3 binding at the ITGB6 and ITGAM promoters was increased in spheroids compared to that in monolayer cells, and the binding was decreased when SMYD3 expression was inhibited, consistent with the expression changes in integrins. SMYD3 expression and integrin‐mediated adhesion were also activated in an intraperitoneal xenograft model and in EOC patient spheroids. In vivo, SMYD3 knockdown inhibited tumor metastasis and reduced ascites volume in both the intraperitoneal xenograft model and a PDX model. Overall, our results suggest that the SMYD3‐H3K4me3‐integrin pathway plays a crucial role in ovarian cancer metastasis to the peritoneal surface.

Adult dietary fat intake and ovarian cancer risk

The association of dietary fat intake with ovarian cancer risk has been inconsistent across populations. We examined dietary fat intake, overall and by type and ovarian cancer risk in two prospective cohort studies. We assessed long‐term dietary fat intake among Nurses’ Health Study (NHS) and NHSII participants using food frequency questionnaires administered every 2–4 years beginning in 1984 and 1991, respectively. We examined cumulative energy‐adjusted intake of total fat, specific types of fat (animal, vegetable, saturated, monounsaturated, polyunsaturated and trans fat) and cholesterol. We identified 700 ovarian cancer cases in NHS and 196 in NHSII with dietary information. Cox proportional hazards regression was used to estimate associations between intake and ovarian cancer risk. Dietary fat intake changed over time in both cohorts and was lower in NHS than NHSII. Higher cumulative average intakes of animal fat and cholesterol were significantly positively associated with risk of ovarian cancer in NHS (relative risk [RR] comparing extreme quartiles = 1.57, 95% CI: 1.20, 2.06 and 1.35, 95% CI: 1.08, 1.69, respectively), but not in NHSII. Other dietary fat sources were not clearly associated with risk in either population. We did not observe clear associations between dietary fat and ovarian cancer risk in two large prospective cohort studies.

Final results from GCIG/ENGOT/AGO‐OVAR 12, a randomised placebo‐controlled phase III trial of nintedanib combined with chemotherapy for newly diagnosed advanced ovarian cancer

AGO‐OVAR 12 investigated the effect of adding the oral triple angiokinase inhibitor nintedanib to standard front‐line chemotherapy for advanced ovarian cancer. At the primary analysis, nintedanib demonstrated significantly improved progression‐free survival (PFS; primary endpoint) compared with placebo. We report final results, including overall survival (OS). Patients with primary debulked International Federation of Gynaecology and Obstetrics (FIGO) stage IIB–IV newly diagnosed ovarian cancer were randomised 2:1 to receive carboplatin (area under the curve 5 or 6) plus paclitaxel (175 mg/m2) on day 1 every 3 weeks for six cycles combined with either nintedanib 200 mg or placebo twice daily on days 2–21 every 3 weeks for up to 120 weeks. Between December 2009 and July 2011, 1,366 patients were randomised (911 to nintedanib, 455 to placebo). Disease was considered as high risk (FIGO stage III with >1 cm residuum, or any stage IV) in 39%. At the final analysis, 605 patients (44%) had died. There was no difference in OS (hazard ratio 0.99, 95% confidence interval [CI] 0.83–1.17, p = 0.86; median 62.0 months with nintedanib vs. 62.8 months with placebo). Subgroup analyses according to stratification factors, clinical characteristics and risk status showed no OS difference between treatments. The previously reported PFS improvement seen with nintedanib did not translate into an OS benefit in the nonhigh‐risk subgroup. Updated PFS results were consistent with the primary analysis (hazard ratio 0.86, 95% CI 0.75–0.98; p = 0.029) favouring nintedanib. The safety profile was consistent with previous reports.

Identification of novel epithelial ovarian cancer loci in women of African ancestry

Women of African ancestry have lower incidence of epithelial ovarian cancer (EOC) yet worse survival compared to women of European ancestry. We conducted a genome‐wide association study in African ancestry women with 755 EOC cases, including 537 high‐grade serous ovarian carcinomas (HGSOC) and 1,235 controls. We identified four novel loci with suggestive evidence of association with EOC (p < 1 × 10−6), including rs4525119 (intronic to AKR1C3), rs7643459 (intronic to LOC101927394), rs4286604 (12 kb 3′ of UGT2A2) and rs142091544 (5 kb 5′ of WWC1). For HGSOC, we identified six loci with suggestive evidence of association including rs37792 (132 kb 5′ of follistatin [FST]), rs57403204 (81 kb 3′ of MAGEC1), rs79079890 (LOC105376360 intronic), rs66459581 (5 kb 5′ of PRPSAP1), rs116046250 (GABRG3 intronic) and rs192876988 (32 kb 3′ of GK2). Among the identified variants, two are near genes known to regulate hormones and diseases of the ovary (AKR1C3 and FST), and two are linked to cancer (AKR1C3 and MAGEC1). In follow‐up studies of the 10 identified variants, the GK2 region SNP, rs192876988, showed an inverse association with EOC in European ancestry women (p = 0.002), increased risk of ER positive breast cancer in African ancestry women (p = 0.027) and decreased expression of GK2 in HGSOC tissue from African ancestry women (p = 0.004). A European ancestry‐derived polygenic risk score showed positive associations with EOC and HGSOC in women of African ancestry suggesting shared genetic architecture. Our investigation presents evidence of variants for EOC shared among European and African ancestry women and identifies novel EOC risk loci in women of African ancestry.

Lifetime recreational moderate‐to‐vigorous physical activity and ovarian cancer risk: A case–control study

Results of epidemiologic studies of physical activity and ovarian cancer risk are inconsistent. Few have attempted to measure physical activity over the lifetime or in specific age windows, which may better capture etiologically relevant exposures. We examined participation in moderate‐to‐vigorous recreational physical activity (MVPA) in relation to ovarian cancer risk. In a population‐based case–control study conducted in Montreal, Canada from 2011 to 2016 (485 cases and 887 controls), information was collected on lifetime participation in various recreational physical activities, which was used to estimate MVPA for each participant. MVPA was represented as average energy expenditure over the lifetime and in specific age‐periods in units of metabolic equivalents (METs)‐hours per week. Odds ratios (OR) and 95% confidence intervals (CI) for the relation between average MVPA and ovarian cancer risk were estimated using multivariable logistic regression models. Confounding was assessed using directed acyclic graphs combined with a change‐in‐estimate approach. The adjusted OR (95% CI) for each 28.5 MET‐hr/week increment of lifetime recreational MVPA was 1.11 (0.99–1.24) for ovarian cancer overall. ORs for individual age‐periods were weaker. When examined by menopausal status, the OR (95% CI) for lifetime MVPA was 1.21 (1.00–1.45) for those diagnosed before menopause and 1.04 (0.89–1.21) for those diagnosed postmenopausally. The suggestive positive associations were stronger for invasive ovarian cancers and more specifically for high‐grade serous carcinomas. These results do not support a reduced ovarian cancer risk associated with MVPA.

Early life physical activity and risk of ovarian cancer in adulthood

AbstractEmerging data suggest that exposures in early life may affect ovarian development and contribute to ovarian cancer risk. We evaluated the association between early life physical activity and risk of ovarian cancer in adulthood in two large prospective cohorts, the Nurses' Health Study (NHS) and NHSII. In total, analyses included 28 232 NHS participants (followed from 2004 to 2016) and 56 553 NHSII participants (followed from 1997 to 2017). Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for risk of ovarian cancer overall and by early life body mass index (BMI). Neither physical activity at ages 12‐13, 14‐17 or 18‐22 years nor average physical activity across these three periods was associated with ovarian cancer risk overall (≥78 vs <24 MET‐h/wk, HRs = 1.34, 1.21, 1.08 and 1.24, respectively), or by categories of early life BMI (Pheterogeneity ≥ .44). No association was observed with the risk of high‐grade serous or poorly differentiated tumors or postmenopausal ovarian cancer. Overall, early life physical activity was not clearly related to ovarian cancer risk during adulthood.

Childhood ovarian nonseminomatous germ cell tumors: A highly curable disease with few long‐term treatment‐related toxicities—Results of the French TGM95 study

AbstractWe report survival and late effects analysis of TGM95 study for childhood (≤18 years) ovarian nonseminomatous germ cell tumors (NS‐GCT). Patients with localized tumors (FIGO‐stage IA) had no adjuvant treatment (low‐risk, LR). Patients with advanced‐stage received 3‐5 VBP (vinblastin‐bleomycin‐cisplatin) in intermediate‐risk group (IR: FIGO‐stage IC‐II‐III and AFP < 15 000 ng/mL) or 4‐6 VIP (etoposide‐ifosfamide‐cisplatin) in high‐risk group (HiR: metastatic or AFP ≥ 15 000 ng/mL). Seventy‐seven patients were included (median age = 12 years): 14 LR (13 FIGO‐stage IA, 1 retrospectively IC), 26 IR (12 IC, 12 II‐III, 2 not‐available) and 37 HiR (2 IA with AFP ≥ 15 000 ng/mL, 27 II‐III, 8 IV). After a median follow‐up of 13.4 years, 12 events (eight relapses) and six deaths (two GCT‐related, two due to acute myeloid leukemia and two noncancer related) occurred. All relapses (6 LR, 1 IR) occurred within 2 years. Four contralateral mature teratomas were observed within 8 years. Five‐year EFS and OS were 88.2% (95%CI = 79‐94%) and 94.6% (95%CI = 87‐98%). Seven patients (9%) had bilateral gonadectomy. Among 51 survivors at 2 years aged >15 years (median = 26 years) with remaining ovarian tissue, all had developed spontaneous puberty and 21 (41%) had at least one pregnancy (including two with infertility treatment). Among 69 patients treated with platinum‐based chemotherapy, chronic‐kidney‐disease was diagnosed in four patients (three after VIP) and significant ototoxicity occurred in three (all grade‐2). Childhood ovarian NS‐GCTs have an excellent prognosis with few late effects. The low‐intensive etoposide‐free VBP regimen could be an alternative in children with IR disease especially in cases of tumor rupture. The risk of contralateral mature teratoma needs regular monitoring of the remaining ovary.

The prevalence of mismatch repair deficiency in ovarian cancer: A systematic review and meta‐analysis

AbstractOvarian cancer (OC) is the least survivable gynecological malignancy and presents late. Five‐year survival for OC is around 45% increasing the need for innovative treatments. Checkpoint inhibitors have shown significant clinical efficacy in mismatch repair deficient (MMRd) cancers and could be a powerful treatment in OC. However, their application in OC is limited due to the lack of data on the prevalence of MMRd. The aim of our study was to conduct a systematic review of the literature and meta‐analysis to provide an accurate estimate of the prevalence of MMRd in OC. We followed PRISMA guidelines throughout. Studies were identified by electronic searches of Medline, Embase, Cochrane CENTRAL and Web of Science followed by citation searching. Studies not written in English were excluded. All studies were reviewed by at least two independent reviewers. Proportions of test positivity were calculated by random and fixed‐effects meta‐analysis models.I2score was used to assess heterogeneity across studies. In total 54 studies were included with 17 532 analyzed for MMRd. The overall proportions of MMRd by immunohistochemistry and microsatellite instability analysis were 6.7% and 10.4%, respectively. MMRd was reported in all histotypes of epithelial OC but was most common in endometrioid OC. We estimate that on average 46.7% (95% CI: 28.8‐65.4) of ovarian carcinomas showing MMRd by IHC had a germline path_MMR variant identified. OC in those with Lynch syndrome seems to present at an earlier age and stage. Studies however were generally of low quality and there was a high degree of heterogeneity. A significant minority (up to 16%) of OC displays MMRd and, therefore, could be amenable to checkpoint inhibition therapy. However, the current literature base is of limited quality and therefore high‐quality prospective studies exploring MMRd in OC with the use of multimodal testing are required. In addition, trials researching efficacy of checkpoint inhibition in MMRd OC are needed.

Prediagnosis and postdiagnosis leisure time physical activity and survival following diagnosis with ovarian cancer

AbstractLittle is known about the influence of prediagnosis and postdiagnosis physical activity on ovarian cancer survival. We investigated this association in two large cohorts, the Nurses' Health Study (NHS) and NHSII. Analyses included 1461 women with confirmed invasive, epithelial ovarian cancer and data on physical activity. Cox regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for ovarian cancer‐specific mortality. Ovarian cancer‐specific mortality was not associated with physical activity reported 1‐8 years before diagnosis overall (≥7.5 vs <1.5 MET‐hours/week, HR = 0.96), for high‐grade serous/ poorly differentiated tumors, or non‐serous/ low‐grade serous tumors (P‐heterogeneity = .45). An inverse association was observed for activity 1‐4 years after diagnosis (≥7.5 vs <1.5 MET‐hours/week, HR = 0.67, 95%CI: 0.48‐0.94), with similar results by histotype (P‐heterogeneity = .53). Women who decreased their activity from ≥7.5 MET‐hours/week 1‐8 years before diagnosis to <7.5 MET‐hours/week 1‐4 years after diagnosis, compared to those with <7.5 MET‐hours/week across periods, had a 49% increased risk of death (HR = 1.49, 95%CI: 1.07‐2.08). Physical activity after, but not before, ovarian cancer diagnosis was associated with better prognosis.

Antibodies against high‐risk human papillomavirus proteins as markers for noncervical HPV‐related cancers in a Black South African population, according to HIV status

AbstractHuman papillomavirus (HPV) proteins may elicit antibody responses in the process toward HPV‐related malignancy. However, HPV seroepidemiology in noncervical HPV‐related cancers remains poorly understood, particularly in populations with a high prevalence of human immunodeficiency virus (HIV). Using a glutathione S‐transferase‐based multiplex serology assay, antibodies against E6, E7 and L1 proteins of HPV16 and HPV18 were measured in sera of 535 cases of noncervical HPV‐related cancers (anal (n = 104), vulval (n = 211), vaginal (n = 49), penile (n = 37) and oropharyngeal (n = 134)) and 6651 non‐infection‐related cancer controls, from the Johannesburg Cancer Study that recruited Black South African with newly diagnosed cancer between 1995 and 2016. Logistic and Poisson regression models were used to calculate adjusted odds ratios (aOR) and prevalence ratios (aPR) and 95% confidence intervals (CI) in cases versus controls. HPV16 E6 was more strongly associated with noncervical HPV‐related cancers than HPV16 L1 or E7, or HPV18 proteins: anal (females (HPV16 E6 aOR = 11.50;95%CI:6.0–22.2), males (aOR = 10.12;95%CI:4.9–20.8), vulval (aOR = 11.69;95%CI:7.9–17.2), vaginal (aOR = 10.26;95%CI:5.0–21), penile (aOR = 18.95;95%CI:8.9–40), and oropharyngeal (females (aOR = 8.95;95%CI:2.9–27.5), males (aOR = 3.49;95%CI:1.8–7.0)) cancers. HPV16‐E6 seropositivity ranged from 24.0% to 35.1% in anal, vulval, vaginal and penile cancer but was significantly lower (11.2%) in oropharyngeal cancer. After adjustment for HIV, prevalence of which increased from 22.2% in 1995–2005 to 54.1% in 2010–2016, HPV16 E6 seropositivity increased by period of diagnosis (aPR for 2010–2016 vs. 1995–2006 = 1.84;95%CI:1.1–3.0). Assuming HPV16 E6 seroprevalence reflects HPV attributable fraction, the proportion of certain noncervical‐HPV‐related cancers caused by HPV is increasing over time in South Africa. This is expected to be driven by the increasing influence of HIV.

First‐ and second‐degree family history of ovarian and breast cancer in relation to risk of invasive ovarian cancer in African American and white women

AbstractFamily history (FH) of ovarian cancer and breast cancer are well‐established risk factors for ovarian cancer, but few studies have examined this association in African American (AA) and white women by histotype. We assessed first‐ and second‐degree FH of ovarian and breast cancer and risk of epithelial ovarian cancer in the Ovarian Cancer in Women of African Ancestry Consortium. Analyses included 1052 AA cases, 2328 AA controls, 2380 white cases and 3982 white controls. Race‐specific odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using multilevel logistic regression with adjustment for covariates. Analyses were stratified by histotype (high‐grade serous vs others). First‐degree FH of ovarian cancer was associated with high‐grade serous carcinoma in AA (OR = 2.32, 95% CI: 1.50, 3.59) and white women (OR = 2.48, 95% CI: 1.82, 3.38). First‐degree FH of breast cancer increased risk irrespective of histotype in AAs, but with high‐grade serous carcinoma only in white women. Associations with second‐degree FH of ovarian cancer were observed for overall ovarian cancer in white women and with high‐grade serous carcinoma in both groups. First‐degree FH of ovarian cancer and of breast cancer, and second‐degree FH of ovarian cancer is strongly associated with high‐grade serous ovarian carcinoma in AA and white women. The association of FH of breast cancer with high‐grade serous ovarian carcinoma is similar in white women and AA women, but may differ for other histotypes.

DNA methylation markers as triage test for the early identification of cervical lesions in a Chinese population

AbstractObjective strategies are required in cervical cancer screening. We have identified several DNA methylation markers with high sensitivity and specificity to detect cervical intraepithelial neoplasia 2 or worse (CIN2+) in Dutch women. Our study aims to analyze the diagnostic characteristics of these markers in a Chinese cohort. A total of 246 liquid‐based cytology samples were included, of which 205 women underwent colposcopy due to an abnormal cytology result (atypical squamous cells of undetermined significance [ASCUS] or worse), while 227 were tested high‐risk human papillomavirus (hrHPV) positive. All six individual markers (ANKRD18CP, C13ORF18, EPB41L3, JAM3, SOX1 and ZSCAN1) showed enhanced methylation levels and frequency with increasing severity of the underlying lesion (P ≤ .001). In cytological abnormal women, sensitivity to detect CIN2+ was 79%, 76% and 72% for the three panels (C13ORF18/EBP41L3/JAM3, C13ORF18/ANKRD18CP/JAM3 and ZSCAN1/SOX1, respectively), with a specificity of 57%, 65% and 68%. For the first two panels, these diagnostic characteristics were similar to the Dutch cohort, while for ZSCAN1/SOX1 the sensitivity was higher in the Chinese cohort, but with a lower specificity (both P < .05). In hrHPV‐positive samples, similar sensitivity and specificity for the detection of CIN2+ were found as for the abnormal cytology cohort, which were now all similar between both cohorts and non‐inferior to HPV16/18 genotyping. Our analysis reveals that the diagnostic performances are highly comparable for C13ORF18/EBP41L3/JAM3 and C13ORF18/ANKRD18CP/JAM3 methylation marker panels in both Chinese and Dutch cohorts. In conclusion, methylation panels identified in a Dutch population are also applicable for triage testing in cervical cancer screening in China.

Risk of nonovarian cancer in a nationwide‐based study of nearly 5000 women with borderline ovarian tumors in Denmark

AbstractEvidence regarding cancer risk after borderline ovarian tumors (BOTs) is limited. We conducted a nationwide cohort study examining the incidence of nonovarian cancers in women with serous or mucinous BOTs compared with the general female population with up to 41 years of follow‐up. Through the nationwide Pathology Registry, we identified nearly 5000 women with BOTs (2506 serous and 2493 mucinous) in Denmark, 1978 to 2018. We computed standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) as relative risk estimates of specific nonovarian cancers. Compared with general female population rates, women with serous BOTs had increased rates of particularly malignant melanoma (SIR = 1.9; 95% CI: 1.3‐2.6), thyroid cancer (SIR = 3.0; 95% CI: 1.4‐5.4) and myeloid leukemia (SIR = 3.2; 95% CI: 1.5‐5.8), and women with mucinous BOTs had elevated rates of lung cancer (SIR = 1.7; 95% CI: 1.3‐2.1), pancreatic cancer (SIR = 1.9; 95% CI: 1.2‐2.9) and myeloid leukemia (SIR = 2.3; 95% CI: 0.9‐4.7). We found no convincing association with neither breast nor colorectal cancer in women with BOTs. This is the first large nationwide study showing that women with specific types of BOTs have increased risks of several nonovarian cancers, likely due to some shared risk factors or genetic characteristics.

Proteomic signature for detection of high‐grade ovarian cancer in germline BRCA mutation carriers

AbstractNo current screening methods for high‐grade ovarian cancer (HGOC) guarantee effective early detection for high‐risk women such as germline BRCA mutation carriers. Therefore, the standard‐of‐care remains risk‐reducing salpingo‐oophorectomy (RRSO) around age 40. Proximal liquid biopsy is a promising source of biomarkers, but sensitivity has not yet qualified for clinical implementation. We aimed to develop a proteomic assay based on proximal liquid biopsy, as a decision support tool for monitoring high‐risk population. Ninety Israeli BRCA1 or BRCA2 mutation carriers were included in the training set (17 HGOC patients and 73 asymptomatic women), (BEDOCA trial; ClinicalTrials.gov Identifier: NCT03150121). The proteome of the microvesicle fraction of the samples was profiled by mass spectrometry and a classifier was developed using logistic regression. An independent cohort of 98 BRCA mutation carriers was used for validation. Safety information was collected for all women who opted for uterine lavage in a clinic setting. We present a 7‐protein diagnostic signature, with AUC >0.97 and a negative predictive value (NPV) of 100% for detecting HGOC. The AUC of the biomarker in the independent validation set was >0.94 and the NPV >99%. The sampling procedure was clinically acceptable, with favorable pain scores and safety. We conclude that the acquisition of Müllerian tract proximal liquid biopsies in women at high‐risk for HGOC and the application of the BRCA‐specific diagnostic assay demonstrates high sensitivity, specificity, technical feasibility and safety. Similar classifier for an average‐risk population is warranted.

Ultra‐processed food consumption and the risk of pancreatic cancer in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial

AbstractWhether ultra‐processed food consumption is associated with the risk of pancreatic cancer has not been determined. We performed a prospective study to fill this gap. A population‐based cohort of 98 265 American adults was identified from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. Ultra‐processed foods were defined by the NOVA classification. Cox regression was used to estimate hazard ratios (HRs) for pancreatic cancer incidence. Subgroup analysis was performed to identify the potential effect modifiers. During a mean follow‐up of 8.86 years, 387 pancreatic cancer cases occurred. High consumption of ultra‐processed foods was found to be associated with an increased risk of pancreatic cancer (fully adjusted HRquartile 4 vs 1:1.49; 95% confidence interval [CI]: 1.07‐2.07; Ptrend = .021) in a linear dose‐response manner (Pnonlinearity = .075). Subgroup analysis further found that the positive association of ultra‐processed food consumption with the risk of pancreatic cancer was more pronounced in subjects aged <65 years (HRquartile 4 vs 1:2.17; 95% CI: 1.14‐4.15) than in those aged ≥65 years (HRquartile 4 vs 1:1.32; 95% CI: 0.88‐1.94), though the interaction test failed to achieve the statistical significance (Pinteraction = .061). These findings suggest that reducing ultra‐processed food consumption may be beneficial in decreasing pancreatic cancer incidence.

The combined action of monocytic myeloid‐derived suppressor cells and mucosal‐associated invariant T cells promotes the progression of cervical cancer

AbstractOne of the most common promoters of the initiation and growth of the tumor is an immune disturbance. Numerous immune cells and inflammatory factors play a role in the tumor‐immune microenvironment. However, few studies have investigated the correlation between these immunological events and clinical consequences in cervical cancer. We measured the levels of numerous inflammatory mediators and frequencies of regulatory T cells (Tregs), myeloid‐derived suppressor cells (MDSCs) and mucosal‐associated invariant T (MAIT) cells in peripheral blood (PB) of cervical cancer patients. Cervical cancer patients showed elevated production of interleukin (IL)‐18 and plasma C‐C chemokine ligand (CCL) 3/5. Meanwhile, an accumulation of C‐C chemokine receptor 5 (CCR5) monocytic (Mo)‐MDSCs and Tregs was observed. The cervical cancer group displayed increased frequencies of CD8+, CD4+and highly activated CD38+CD8+MAIT cells, and reduction of double‐negative (DN) and PD1(CD279+) DN MAIT cells. Importantly, it was demonstrated that MAIT cells were positively related to Mo‐MDSCs. Furthermore, an elevated concentration of PD1(CD279+) DN MAIT cells was significantly related to increased progression‐free survival of patients with cervical cancer. In conclusion, our study suggests that the combined action of Mo‐MDSCs and MAIT cells might be associated with the progression of cervical cancer, and the frequency of DN MAIT cells in the peripheral blood mononuclear cells was associated with the survival benefit of patients.

Reply to: Comments on “Effect of HIPEC according to HRD/BRCAwt genomic profile in stage III ovarian cancer: Results from the phase III OVHIPEC trial”

Comments on “Effect of HIPEC according to HRD/BRCAwt genomic profile in stage III ovarian cancer: Results from the phase III OVHIPEC trial”

Long‐term survival of nonlocalized epithelial ovarian cancer among women using menopausal hormone therapy prior to diagnosis: The extreme study

AbstractPrediagnostic use of menopausal hormone therapy (MHT) has been suggested to be associated with improved survival of epithelial ovarian cancer (EOC). We investigated the potential long‐term survival benefit of prediagnostic MHT use in women ≥50 years with nonlocalized EOC using the Extreme study including all women in Denmark registered with nonlocalized EOC during 2000 to 2014 (N = 3776). We obtained individual‐level information on prediagnostic use of systemic estrogen therapy (ET) and estrogen plus progestin therapy (EPT) from the National Prescription Registry and estimated absolute and relative 5‐ and 10‐year survival probabilities with 95% confidence intervals (CIs) using pseudo‐values, taking into account histology, comorbidity, income and residual disease. Among women not having used prediagnostic MHT, 5‐ and 10‐year absolute survival probabilities were 19% and 11%, respectively. Compared to MHT nonusers, prediagnostic systemic ET use for 3 to 4 years and ≥ 5 years was associated with 1.43 (95% CI: 1.01‐2.02) and 1.22 (95% CI: 0.96‐1.55) times higher 5‐year survival probabilities, respectively. Ten‐year survival probabilities were also increased but not statistically significantly. Among prediagnostic EPT users, increased 5‐year (1.14, 95% CI: 0.85‐1.53) and 10‐year (1.38, 95% CI: 0.91‐2.08) survival probabilities were observed after use for 3 to 4 years compared to MHT nonuse, whereas EPT use for ≥5 years was not associated with long‐term survival of nonlocalized EOC. Our findings may suggest a better long‐term survival of nonlocalized EOC in women having used long‐term prediagnostic ET. However, the statistical precision of our results did not allow firm conclusions and more studies are needed.

Racial disparities in epithelial ovarian cancer survival: An examination of contributing factors in the Ovarian Cancer in Women of African Ancestry consortium

AbstractBlack women diagnosed with epithelial ovarian cancer have poorer survival compared to white women. Factors that contribute to this disparity, aside from socioeconomic status and guideline‐adherent treatment, have not yet been clearly identified. We examined data from the Ovarian Cancer in Women of African Ancestry (OCWAA) consortium which harmonized data on 1074 Black women and 3263 white women with ovarian cancer from seven US studies. We selected potential mediators and confounders by examining associations between each variable with race and survival. We then conducted a sequential mediation analysis using an imputation method to estimate total, direct, and indirect effects of race on ovarian cancer survival. Black women had worse survival than white women (HR = 1.30; 95% CI 1.16‐1.47) during study follow‐up; 67.9% of Black women and 69.8% of white women died. In our final model, mediators of this disparity include college education, nulliparity, smoking status, body mass index, diabetes, diabetes/race interaction, postmenopausal hormone (PMH) therapy duration, PMH duration/race interaction, PMH duration/age interaction, histotype, and stage. These mediators explained 48.8% (SE = 12.1%) of the overall disparity; histotype/stage and PMH duration accounted for the largest fraction. In summary, nearly half of the disparity in ovarian cancer survival between Black and white women in the OCWAA consortium is explained by education, lifestyle factors, diabetes, PMH use, and tumor characteristics. Our findings suggest that several potentially modifiable factors play a role. Further research to uncover additional mediators, incorporate data on social determinants of health, and identify potential avenues of intervention to reduce this disparity is urgently needed.

Effect of HIPEC according to HRD/BRCAwt genomic profile in stage III ovarian cancer: Results from the phase III OVHIPEC trial

AbstractThe addition of hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin to interval cytoreductive surgery improves recurrence‐free (RFS) and overall survival (OS) in patients with stage III ovarian cancer. Homologous recombination deficient (HRD) ovarian tumors are usually more platinum sensitive. Since hyperthermia impairs BRCA1/2 protein function, we hypothesized that HRD tumors respond best to treatment with HIPEC. We analyzed the effect of HIPEC in patients in the OVHIPEC trial, stratified by HRD status and BRCAm status. Clinical data and tissue samples were collected from patients included in the randomized, phase III OVHIPEC‐1 trial. DNA copy number variation (CNV) profiles, HRD‐related pathogenic mutations and BRCA1 promotor hypermethylation were determined. CNV‐profiles were categorized as HRD or non‐HRD, based on a previously validated algorithm‐based BRCA1‐like classifier. Hazard ratios (HR) and corresponding 99% confidence intervals (CI) for the effect of RFS and OS of HIPEC in the BRCAm, the HRD/BRCAwt and the non‐HRD group were estimated using Cox proportional hazard models. Tumor DNA was available from 200/245 (82%) patients. Seventeen (9%) tumors carried a pathogenic mutation in BRCA1 and 14 (7%) in BRCA2. Ninety‐one (46%) tumors classified as BRCA1‐like. The effect of HIPEC on RFS and OS was absent in BRCAm tumors (HR 1.25; 99%CI 0.48‐3.29), and most present in HRD/BRCAwt (HR 0.44; 99%CI 0.21‐0.91), and non‐HRD/BRCAwt tumors (HR 0.82; 99%CI 0.48‐1.42), interaction P value: 0.024. Patients with HRD tumors without pathogenic BRCA1/2 mutation appear to benefit most from treatment with HIPEC, while benefit in patients with BRCA1/2 pathogenic mutations and patients without HRD seems less evident.

Geographic and temporal variations in the incidence of vulvar and vaginal cancers

AbstractVulvar and vaginal cancers are relatively rare cancers, together responsible for less than 1% of the global cancer incidence among women in 2018. The majority of vaginal cancers and a lesser proportion of vulvar cancers are associated with HPV, with rising incidence rates of vulvar cancer observed in younger women, possibly due to an increased prevalence of high‐risk HPV types. This report assesses recent international variations in the incidence rates of vulvar and vaginal cancer derived from high‐quality data from population‐based cancer registries in 68 countries, and further assesses time trends for selected longer‐term series in eight countries (Australia, China, Colombia, India, Norway, Slovakia, the U.S., and the U.K.) over the period 1983 to 2012. We observed a 30‐fold variation in the recorded incidence rates of vulvar cancer in contrast with the threefold variation for vaginal cancer. We also observed a rising incidence of vulvar cancer in Australia, Norway and the U.K., and Slovakia, with a more rapid rise in the rates seen in women aged < 60 years at diagnosis. The annual percentage change over the most recent decade varied from 1.7% in Norway to 4.1% in Slovakia. The increases are largely confined to younger women and are likely linked to generational changes in sexual behaviour (earlier age at sexual debut and increasing transmission of HPV among cohorts born 1940 to 1950 and thereafter. Vaginal cancer incidence rates, in contrast, were lower and more stable, despite the higher HPV‐attributable fraction relative to vulvar cancer. Irrespective of the trends, an increasing number of women are predicted to be diagnosed worldwide with both cancer types in future decades as population ageing and growth continues. The promise of high‐coverage HPV vaccination will likely counter this rising burden, but the impact may take a number of decades.

Diagnostic potential of nanoparticle aided assays for MUC16 and MUC1 glycovariants in ovarian cancer

AbstractOur study reports the discovery and evaluation of nanoparticle aided sensitive assays for glycovariants of MUC16 and MUC1 in a unique collection of paired ovarian cyst fluids and serum samples obtained at or prior to surgery for ovarian carcinoma suspicion. Selected glycovariants and the immunoassays for CA125, CA15‐3 and HE4 were compared and validated in 347 cyst fluid and serum samples. Whereas CA125 and CA15‐3 performed poorly in cyst fluid to separate carcinoma and controls, four glycovariants including MUC16MGL, MUC16STn, MUC1STn and MUC1Tn provided highly improved separations. In serum, the two STn glycovariants outperformed conventional CA125, CA15‐3 and HE4 assays in all subcategories analyzed with main benefits obtained at high specificities and at postmenopausal and early‐stage disease. Serum MUC16STn performed best at high specificity (90%‐99%), but sensitivity was also improved by the other glycovariants and CA15‐3. The highly improved specificity, excellent analytical sensitivity and robustness of the nanoparticle assisted glycovariant assays carry great promise for improved identification and early detection of ovarian carcinoma in routine differential diagnostics.

Feedback‐regulated transcriptional repression of FBXO31 by c‐Myc triggers ovarian cancer tumorigenesis

AbstractFBXO31, a member of F‐box protein family, has been shown to play an important role in preventing tumorigenesis by preserving genomic stability during cell proliferation as well as upon genotoxic stress. Inactivation of FBXO31 due to loss of heterozygosity is associated with various cancers, including ovarian cancer, one of the deadliest forms of gynecological cancers. However, the role and regulation of FBXO31 in ovarian cancer remained elusive. Here, using biochemical and molecular biology techniques, we show that c‐Myc suppresses the mRNA levels of FBXO31 in ovarian cancer. Chromatin immunoprecipitation experiment showed that c‐Myc is recruited to the promoter region of FBXO31 and prevents FBXO31 mRNA synthesis. In contrast, FBXO31 maintains the c‐Myc expression at an optimum through proteasome pathway. FBXO31 interacts with and facilitates the polyubiquitination of c‐Myc through the SCF complex and thereby inhibits ovarian cancer growth both in vitro and in vivo. Moreover, FBXO31‐mediated proteasomal degradation of c‐Myc is unique. Unlike other negative regulators, FBXO31 recognizes c‐Myc in phosphorylation independent manner to direct its degradation. Further, expression levels analysis revealed that c‐Myc and FBXO31 share a converse correlation of expression in ovarian cancer cell lines and patient samples. We observed an increase in the expression levels of c‐Myc with a concomitant decrease in the levels of FBXO31 in higher grades of ovarian cancer patient samples. In conclusion, our study demonstrated that oncogene c‐Myc impairs the tumor‐suppressive functions of FBXO31 to promote ovarian cancer progression, and therefore c‐Myc‐FBXO31 axis can be explored to develop better cancer therapy.

Efficacy of point‐of‐care thermal ablation among high‐risk human papillomavirus positive women in China

AbstractThermal ablation is a point‐of‐care ablative treatment technique for cervical intraepithelial neoplasia (CIN). However, limited information is available about its efficacy in low‐ and middle‐income countries. We evaluated the efficacy of thermal ablation in treatment of CIN detected through high‐risk human papillomavirus (HPV) screening in China. Women positive on high‐risk HPV and having colposcopically suspected lesions eligible for ablation underwent colposcopy, biopsy and thermal ablation in one visit. Women ineligible were recalled for large loop excision of transformation zone (LLETZ) when histopathology results were high‐grade CIN. Posttreatment follow‐up at 6 months or more was with HPV test and cytology followed by colposcopy and biopsy for HPV and/or cytology‐positive women. Cure was defined as either negative cytology and HPV test or absence of histopathology proved CIN in any positive women. Of total 218 HPV‐positive women treated with thermal ablation (n = 170) or LLETZ (n = 48), 196 reported for follow‐up evaluation. For women with histologically confirmed CIN at baseline (thermal ablation‐104; LLETZ‐38), cure rates were 84.6% for thermal ablation and 86.8% for LLETZ. Cure rates after thermal ablation were 90.3% for CIN grade one (CIN1) and 76.2% for CIN grade two or worse (CIN2+). HPV clearance rate was 80.4% in women undergoing thermal ablation, which was lower for HPV16/18 compared to other oncogenic types (67.6% vs 85.7%). HPV test had a negative predictive value (NPV) of 98.7% to detect CIN2+ at follow‐up and the positive predictive value (PPV) was 40.4%. Thermal ablation is effective to treat CIN as well as to clear the high‐risk HPV infection. HPV test has high PPV and NPV in following up patients posttreatment.

Molecular and pathological basis of HPV‐negative cervical adenocarcinoma seen in a global study

AbstractInternational surveys find HPV‐negativity in up to 30% of cervical adenocarcinomas. We investigated the pathological diagnosis by expert consensus with immunohistochemistry and the presence of somatic mutations in recognised tumour genes in HPV‐positive and negative cervical adenocarcinomas (CADC). A sample was selected of 45 paraffin‐embedded cervical blocks diagnosed locally as usual cervical adenocarcinoma from a global study. These represented different diagnoses made at previous diagnostic review and HPV status. All were suitable for analysis for somatic tumour associated gene mutations. Three pathologists examined H/E slides and immunohistochemistry for p16, progesterone receptor and p53 and classified the cases. L1 genes from high‐risk HPVs and low‐risk HPVs were analysed by SPF10 PCR‐DEIA‐LiPA25 version 1 in whole tissue sections and microdissected tumour and retested by PCR for E6/E7 genes of hrHPVs if negative. Cases were analysed for microsatellite instability and next‐generation sequencing mutation analysis. From the 45 cases, 20 cases of usual CADC were confirmed of which 17 (85%) were HPV‐positive in tumour cells. The other 25 cases were reclassified as endometrial, serous, clear‐cell and gastric‐type adenocarcinomas and all were HPV‐negative in tumour cells. Careful retesting for HPV DNA and IHC leads to more accurate identification of HPV‐positive usual cervical adenocarcinomas. Endometrioid endometrial adenocarcinomas, other uterine adenocarcinoma with multiple somatic mutations were important in misclassification of HPV‐negative cases locally managed as cervical adenocarcinoma, as was gastric‐type adenocarcinoma with germline STK11 mutation in East Asia. Few consensuses confirmed HPV‐negative usual cervical adenocarcinomas showed somatic tumorigenic mutations also seen in some HPV‐positive usual CADC.

Peritoneal HPV‐DNA test in cervical cancer (PIONEER study): A proof of concept

AbstractThe aim of this study was to investigate the prevalence of peritoneal human papillomavirus (HPV) infection in different clinical cervical cancer (CC) settings, and its association with potential clinical and/or histological factors. This is a single‐center, prospective, observational study. Consecutive patients with newly diagnosed or recurrent/persistent CC, between March 2019 and April 2020, were included. A group of patients undergoing surgery for benign gynecological conditions was included as control group. All patients underwent HPV‐DNA test in the cervix and in the peritoneal cavity simultaneously at time of surgery. Two‐hundred seventy‐two patients had cervical and peritoneal HPV test analyzed. Cervical and peritoneal HPV positivity (PHP) was found in 235 (88.0%) and 78 (28.7%) patients, respectively; the prevalence of PHP was 17.7% in early stage, 28.8% in locally advanced cervical cancer (LACC) and 46.6% in the metastatic/persistent/recurrent setting (P = .001). No control patient was found to have peritoneal HPV infection. Higher frequency of PHP was documented in patients with larger tumor size (P = .003), presence of cervical HPV 16/18 genotypes (P < .001), higher number of cervical high‐risk (HR)‐HPV per patient (P = .018) and peritoneal carcinomatosis (P < .001). Multivariate analysis demonstrated that lack of preoperative cervical conization in early stages (P = .030), while higher International Federation of Gynecology and Obstetrics (FIGO) stage (P = .021) and presence of cervical HPV 16/18 (P = .001) in LACC, was associated with PHP. This is a proof‐of‐concept study. A number of potential clinical implications, including prognosis, could be obtained by further studies.

Dynamic analysis of circulating tumor DNA to predict prognosis and monitor therapeutic response in metastatic relapsed cervical cancer

AbstractLimited and inefficient treatment options exist for metastatic relapsed cervical cancer (MRCC), and there are currently no reliable indicators to guide therapeutic selection. We performed deep sequencing analyses targeting 322 cancer‐related genes in plasma cell‐free DNA and matched white blood cells in 173 serial blood samples from 82 locally advanced CC (LACC) or MRCC patients and when possible during treatment. We identified five notable nonsynonymous mutant genes (PIK3CA, BRAF, GNA11, FBXW7 and CDH1) in the MRCC samples as the metastatic relapse significantly mutated (MSG) genes and found that MRCC patients with any detectable MSG mutations had significantly shorter progression‐free survival (PFS) (P = .005) and overall survival (OS) (P = .007) times than those without detectable MSG mutations. Additionally, analyses of matched prechemotherapy and postchemotherapy plasma revealed that a reduction in the number of MSG mutations after chemotherapy was significantly associated with partial remission (PR) and stable disease (SD) (P = .007). Among the patients included in the longitudinal tracking ctDNA analysis, an increase in MSG mutations was observed earlier in response to disease progression than radiological imaging. Our results outline the mutation profiles of MRCC. We show how longitudinal monitoring with ctDNA in liquid biopsy samples provides both predictive and prognostic information during treatment.

Dual staining for p16/Ki‐67 to detect high‐grade cervical lesions: Results from the Screening Triage Ascertaining Intraepithelial Neoplasia by Immunostain Testing study

AbstractWe compared clinical performance of p16/Ki‐67 dual‐stained cytology and human papillomavirus (HPV) genotyping, via different algorithms—alone, or in combination with cytology—to identify cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and grade 3 or worse (CIN3+) in women referred to as colposcopy. We included 492 cervical specimens (134 normal, 130 CIN1, 99 CIN2, 121 CIN3, 8 cancers) randomly selected from 1158 specimens with valid conventional cytology, HPV (cobas 4800 HPV test) and biopsy results. Dual‐stained cytology was retrospectively performed (CINtec PLUS assay) on PreservCyt material; slides were read by a cytologist and confirmed by two pathologists, blinded to cytology, biopsy and genotyping results. Sensitivity and specificity (95% confidence intervals in parentheses) of dual‐stained cytology to detect CIN2+ and CIN3+ were compared to other screening tests available for the same women. Positivity rate for dual‐stained cytology increased with histological severity: 30.6% in normal, 41.5% in CIN1, 72.7% in CIN2, 86.8% in CIN3 and 87.5% in cancer. Dual‐stained cytology alone had lower sensitivity than HPV testing for CIN2+ [80.7% (75.0‐85.6) vs 89.9% (85.3‐93.5)] and CIN3+ [86.8% (79.7‐92.1) vs 92.3% (86.2‐96.2)]. However, corresponding specificity values were higher [64.0% (57.9‐69.8) vs 56.1% (49.8‐62.1) for CIN2+; 54.0% (48.7‐59.2) vs 44.4% (39.2‐49.6) for CIN3+]. Combining dual‐stained cytology with an ASC‐US abnormality threshold decreased specificity to 31.4% (25.9‐37.4) for CIN2+ and 24.2% (19.9‐29.0) for CIN3+. The corresponding values considering low squamous intraepithelial lesion threshold values were 42.8% (36.8‐49.0) and 35.0% (30.1‐40.1). Dual‐stained cytology and HPV testing exhibited similar performance, although the former improved the specificity by 7.9% and 9.6% for CIN2+ and CIN3+, respectively.

Detection of high‐grade cervical disease among women referred directly to colposcopy after a positive HPV screening test varies with age and cytology findings

AbstractAustralia's new HPV‐based cervical screening program is based on an algorithm that incorporates reflex cytology to guide decisions about further follow‐up with colposcopy and, if indicated, biopsy. We reviewed results for 2300 women referred directly for colposcopy after their first positive HPV screening test, to determine the proportion that had underlying histological high‐grade abnormality (HGA). Overall, HGA was detected in 24.3% of women. Among HPV16/18 positive women, 18.0% had HGA, increasing from 6.6% among women with negative cytology to 79.7% among women with high‐grade squamous lesion or worse, or any glandular lesion on cytology (HSIL+; P‐trend < .001). For this latter group, the proportion with HGA was higher among HPV16/18 positive women than among those positive for other oncogenic types (68.8%; P = .029). Among women with ASC‐H cytology, 51.8% had HGA, with no difference between HPV groups (P = .314). In analyses by age‐groups, detection of HGA was highest, at 36.4%, among women younger than 35 years, then decreased significantly to 5.9%, among women aged 65 to 74 years (P‐trend < .001). The relationship of decreasing HGA detection with increasing age was strong for women with negative cytology, and those with ASC‐H cytology (P‐trend < .001 for each). For women with HSIL+ cytology, detection of HGA was high and stable, regardless of age (P‐trend = .211). This report describes the first follow‐up colposcopy findings in Australia's new HPV‐based cervical screening program. The results demonstrate the additional value of reflex cytology in managing HPV positive women and suggest that further refinement of the risk‐based algorithm to account for age may be warranted.

Cervical cancer survival in sub‐Saharan Africa by age, stage at diagnosis and Human Development Index: A population‐based registry study

AbstractCervical cancer is the leading cause of cancer death in African women. We sought to estimate population‐based survival and evaluate excess hazards for mortality in African women with cervical cancer, examining the effects of country‐level Human Development Index (HDI), age and stage at diagnosis. We selected a random sample of 2760 incident cervical cancer cases, diagnosed in 2005 to 2015 from 13 population‐based cancer registries in 11 countries (Benin, Cote d'Ivoire, Ethiopia, Kenya, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Uganda and Zimbabwe) through the African Cancer Registry Network. Of these, 2735 were included for survival analyses. The 1‐, 3‐ and 5‐year observed and relative survival were estimated by registry, stage and country‐level HDI. We used flexible Poisson regression models to estimate the excess hazards for death adjusting for age, stage and HDI. Among patients with known stage, 65.8% were diagnosed with Stage III‐IV disease. The 5‐year relative survival for Stage I‐II cervical cancer in high HDI registry areas was 67.5% (42.1‐83.6) while it was much lower (42.2% [30.6‐53.2]) for low HDI registry areas. Independent predictors of mortality were Stage III‐IV disease, medium to low country‐level HDI and age >65 years at cervical cancer diagnosis. The average relative survival from cervix cancer in the 11 countries was 69.8%, 44.5% and 33.1% at 1, 3 and 5 years, respectively. Factors contributing to the HDI (such as education and a country's financial resources) are critical for cervical cancer control in SSA and there is need to strengthen health systems with timely and appropriate prevention and treatment programmes.

Cumulative risk of cervical intraepithelial neoplasia for women with normal cytology but positive for human papillomavirus: Systematic review and meta‐analysis

AbstractMost women positive for human papillomavirus (HPV) are cytology normal. The optimal screen‐management of these women is unclear given their risk of developing precancer. We performed a systematic review and meta‐analysis of progression rates to precancer and cancer for HPV‐positive, cytology normal women. We searched MEDLINE, EMBASE and Scopus for prospective studies measuring the cumulative incidence of precancer and cervical cancer in HPV‐positive, cytology/histology normal women. Record screening was performed independently by two reviewers. We modeled the cumulative incidence over time using a multilevel random‐effects meta‐regression model. We used the model to predict HPV type‐specific risks of precancer and cancer over follow‐up. Data from 162 unique records were used in our analysis. The average incidence rate of cervical intraepithelial neoplasia grade 3 or cancer (CIN3+) in high‐risk HPV positive but cytology/histology normal women was 1.0 per 100 women‐years (95% CI: 1.0‐1.1). This corresponds to an average cumulative risk at 1, 3 and 5 years of 2.1% (95% prediction interval 0.0‐9.5), 4.3% (95% prediction interval 0.0‐11.5) and 6.4% (95% prediction interval 0.0‐13.5). HPV type was a strong predictor of the risk of oncogenic progression. There was substantial heterogeneity in the background precancer risk across studies (P‐value < .0001). Our HPV type‐specific progression risk estimates can help inform risk‐based cervical cancer screening guidelines for HPV‐positive women. However, precancer and cervical cancer risks are highly variable and may not be generalizable between populations.

A demonstration of automated visual evaluation of cervical images taken with a smartphone camera

AbstractWe 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.

Association of HPV35 with cervical carcinogenesis among women of African ancestry: Evidence of viral‐host interaction with implications for disease intervention

AbstractHPV35 has been found in only ∼2% of invasive cervical cancers (ICC) worldwide but up to 10% in Sub‐Saharan Africa, warranting further investigation and consideration of impact on preventive strategies. We studied HPV35 and ethnicity, in relation to the known steps in cervical carcinogenesis, using multiple large epidemiologic studies in the U.S. and internationally. Combining five U.S. studies, we measured HPV35 positivity and, in Northern California, observed HPV35 type‐specific population prevalence and estimated 5‐year risk of developing precancer when HPV35‐positive. HPV35 genetic variation was examined for differences in carcinogenicity in 1053 HPV35+ cervical specimens from a U.S. cohort and an international collection. African‐American women had more HPV35 (12.1% vs 5.1%, P < .001) and more HPV35‐associated precancers (7.4% vs 2.1%, P < .001) compared to other ethnicities. Precancer risks after HPV35 infection did not vary by ethnicity (global P = .52). The HPV35 A2 sublineage showed an increased association with precancer/cancer in African‐Americans (OR = 5.6 vs A1, 95% CI = 1.3‐24.8) and A2 was more prevalent among ICC in Africa than other world regions (41.9% vs 10.4%, P < .01). Our analyses support a strong link between HPV35 and cervical carcinogenesis in women of African ancestry. Current HPV vaccines cover the majority of cervical precancer/cancer across all ethnic groups; additional analyses are required to determine whether the addition of HPV35 to the already highly effective nine‐valent HPV vaccine would provide better protection for women in Africa or of African ancestry.

Triage options to manage high‐risk human papillomavirus‐positive women: A population‐based cross‐sectional study from rural China

AbstractImprovement in managing HPV‐positive women is urgently needed. Based on a population‐based study which included 2112 women aged 49 to 69 from Shanxi, China, we aimed to evaluate the clinical performance of multiple triage strategies based on liquid‐based cytology (LBC), p16INK4a, viral load and partial genotyping, as a single or combined strategy for detecting cervical intraepithelial neoplasia grade 2/3 or higher (CIN2+/CIN3+) in women who tested positive by Hybrid Capture 2 (HC2). Among 452 HC2‐positive women, the test positivity of LBC (ASC‐US+), p16INK4a, HPV16/18 and HPV16/18/31/33/45 were 39.6%, 38.5%, 18.0% and 40.0%, respectively. Compared to LBC (ASC‐US+) triage, a single triage strategies using p16INK4a or extended genotyping (SureX HPV16/18/31/33/45) achieved comparable sensitivity (relative sensitivity: 1.08, 95% confidence interval [CI]: 0.93‐1.26 and 0.96, 95% CI: 0.76‐1.22) and specificity (relative specificity: 1.05, 95% CI: 0.96‐1.14 and 1.02, 95% CI: 0.92‐1.14) for CIN3+. Viral load triage using a ≥50 RLU/CO cut‐point also yielded similar results with LBC (ASC‐US+). Among combined triage strategies, HPV16/18 genotyping with reflex p16INK4a showed higher sensitivity and slightly lower specificity than LBC (ASC‐US+) for CIN3+ detection, however, the differences were not statistically significant. Of note, after a negative result by p16INK4a or LBC among HPV16/18 negative women, the posttest probability of CIN3+ was lower than 1%. Our study suggested that p16INK4a, extended genotyping and increased viral load cut‐point could be promising alternatives to cytology triage. Combined triage algorithms of HPV16/18 with reflex p16INK4a or cytology, if negative, are associated with the substantial low posttest risk sufficient to release women to next screening round.

A study of the risks of CIN3+ detection after multiple rounds of HPV testing: Results of the 15‐year cervical cancer screening experience at Kaiser Permanente Northern California

Many countries are transitioning to HPV testing for cervical cancer screening, despite a lack of long‐term experience. To anticipate multi‐round screening performance, we analyzed 15‐year HPV testing results at Kaiser Permanente Northern California (KPNC). We evaluated HPV test result patterns among women aged 30–64 undergoing triennial HPV/cytology cotesting at KPNC during 2003–2018. We calculated incidence rates and proportion of CIN3+ diagnoses associated with the most frequent HPV testing patterns overall and stratified by age. From 2003 to 2018, a total of 1,361,581 women had a valid HPV test result, and 7,087 were diagnosed with CIN3+. Incidence rates of CIN3+ after HPV positivity were lowest when HPV detection was new and highest in women with prevalent infections (770 vs. 13,910/100,000 person‐years). Repeat test negativity reduced subsequent incidence rates of CIN3+ to extremely low levels (18/100,000 person‐years following four consecutive negative results). For mixed patterns of positivity/negativity, the recency and frequency of positive tests were associated with increased rates of CIN3+ diagnosis. Most CIN3+ cases (76%) were diagnosed in women who were positive at baseline (the first known positive HPV result); 16% were attributed to apparent newly detected infections and 3% to possible reappearing infections. These results corroborate previous findings that current HPV positivity, particularly when prevalent rather than new, is associated with the highest rates of CIN3+. In a screening program implementing HPV testing, most CIN3+ is detected at the first HPV positive test.

Cervical cancer burden in Latin America and the Caribbean: Where are we?

In May 2018, the World Health Organization (WHO) called for the elimination of cervical cancer. To monitor this initiative, we examined cervical cancer incidence and mortality in the Latin America and Caribbean (LAC) region using GLOBOCAN 2018, Cancer Incidence in Five Continents Series, and the WHO Mortality Database. We estimated the number of cases and age‐standardized rates (ASRs) for cervical cancer incidence and mortality for 2018. We also presented the ASRs for recorded cervical cancer incidence from the period 2008 to 2012. We calculated annual rates and analyzed trends in cervical cancer incidence and mortality for all ages combined and for the following age groups: 0–29, 30–49, 50–64 and 65+. Finally, we calculated the estimated average annual percentage change in incidence and mortality rates for the past 10 years. In 2018, an estimated 56,000 new cervical cancer cases and 28,000 cervical cancer deaths occurred among women in LAC with great variations between subregions and countries/territories. Overall, trends in cervical cancer incidence and mortality have decreased over the past decade; however, the rates are still above the elimination threshold of 4 per 100,000 in most LAC countries/territories. Despite the encouraging trends observed, achieving the elimination of cervical cancer in the region still requests substantial political commitment and economic effort. Population‐based cancer registries are critical in monitoring the elimination initiative.

Identification of calmodulin‐like protein 5 as tumor‐suppressor gene silenced during early stage of carcinogenesis in squamous cell carcinoma of uterine cervix

AbstractIn the course of identifying the molecular mechanism that is related to strong cell‐cell adhesion in stratified structures of the squamous epithelium, calmodulin‐like protein 5 (CALML5) was identified as a spinous structure‐associated protein by producing monoclonal antibodies with the use of the crude intercellular portion of squamous tissue as an immunogen and by subsequent morphologic screening. By electrophoretic mobility shift assay (EMSA) and a series of mutagenesis studies, two transcription factors, ZNF750 and KLF4, by binding in line to the CALML5 gene promoter, were found to play a central role in CALML5 transcription. Knockdown of CALML5 by siRNA in the A431 cell line that expresses high levels of CALML5 resulted in the acceleration of wound confluence in a scratch assay, indicating that CALML5 functions as a tumor‐suppressor in uterine cervical cancer. Immunohistochemical evaluation of squamous intraepithelial lesions, carcinoma in situ (CIS) and invasive uterine cancer, revealed a reduction in CALML5 expression during the stages of CIS through various molecular pathways including the blockage of the nuclear translocation of KLF4. Conversely, restoration of the nuclear translocation of KLF4 by inhibiting ERK‐signaling reactivated CALML5 expression in ME180 cells expressing low levels of CALML5. Thus, alteration of the p63‐ZNF750‐KLF4 axis may result in critical functional loss of CALM‐related genes during cancer progression. Although the morphological association of CALML5 with the spiny‐structure in relation to cell motility is not clear, evaluation of CALML5 expression provides a useful diagnostic indicator of differentiating dysplasia, preinvasive and invasive cervical cancers.

Identification of HPV genotypes causing cervical precancer using tissue‐based genotyping

Identification of high‐risk human papillomavirus genotypes causing cervical precancer is crucial for informing HPV vaccine development and efficacy studies, and for determining which types to include in next‐generation genotyping assays. Co‐occurrence of hrHPV infections is common and complicates carcinogenicity assessment; accurate attribution requires tissue‐based genotyping of precancers. We included all women with cervical intraepithelial neoplasia Grade 2 or worse (CIN2+) from the Biopsy Study, an observational study of 690 women enrolled between 2009 and 2012 at the University of Oklahoma. Tissue‐based genotyping, including whole tissue sections (WTS) and laser‐capture microdissection (LCM), was performed on all precancers with multiple hrHPV infections detected in cytology, totaling over 1,800 HPV genotyping assays. Genotype attribution was compared to hierarchical and proportional hrHPV‐type attribution models. Of 276 women with CIN2+, 122 (44.2%) had multiple hrHPV genotypes in cytology. Of 114 women with genotyping data, 94 had one or more hrHPV detected in tissue. Seventy‐one women (75.5%) had a single causal hrHPV genotype, while 23 women had multiple hrHPV genotypes causing CIN2+. Ten women had multiple causal infections in a single biopsy, contrary to the previous notion that each lesion is caused by a single type only. While HPV16 was the predominant causal hrHPV genotype using all approaches, the hierarchical model overattributed HPV16, whereas other causal hrHPV genotypes, particularly HPV18 and HPV35, were underattributed. Understanding true causal genotypes is important for the evaluation of vaccine efficacy, to estimate the extent of unmasking, and for type‐specific risk assessment in screening and management.

Association between waiting time for radiotherapy initiation and disease progression among women with cervical cancer in Addis Ababa, Ethiopia

AbstractThere is shortage of radiotherapy machines in low‐income countries, including Ethiopia. Data on adverse effects of this on cancer outcomes are limited, however. Herein, we examined the extent of waiting time for radiotherapy and its association with disease progression based on a prospective cohort study of women diagnosed with stage IA‐IVA cervical cancer in Addis Ababa and who were scheduled to receive radiotherapy at Tikur Anbessa Specialized Hospital, the only hospital that provides radiotherapy services in the country. Association was examined using Multivariable mixed effects logistic regression model. Among the 178 women with cervical cancer scheduled for receipt of radiotherapy and with vital status information, 16 deceased (9.0%) while waiting for radiotherapy. For the remaining 162 women who initiated radiotherapy, the median treatment waiting period was 137 days (IQR = 60‐234 days), with 74.1% of women waiting for >60 days. Tumor progressed to higher stage for 44.4% of these women. Compared to those women who initiated radiotherapy ≤60 days after diagnostic confirmation, the odds of tumor progression to higher stage was three times higher in those women who initiated radiotherapy between 120‐179 days (aOR =3.30, 95%CI: 1.18‐9.27) and ≥180 days (aOR =3.06, 95%CI: 1.24‐7.52). Waiting period for receipt of radiotherapy among women with cervical cancer is exceedingly long in Addis Ababa, and it is associated with disease progression to higher stages. These findings reinforce the need to expand radiotherapy infrastructure in order to mitigate the undue high burden of the disease in Ethiopia and other parts of Africa.

Genome‐wide DNA methylation profiling identifies two novel genes in cervical neoplasia

DNA methylation analysis may improve risk stratification in cervical screening. We used a pan‐epigenomic approach to identify new methylation markers along the continuum of cervical intraepithelial neoplasia (CIN) to cervical cancer. Physician‐collected samples (54 normal, 50 CIN1, 40 CIN2 and 42 CIN3) were randomly selected from women at a single‐center colposcopy clinic. Extracted DNA was subjected to Illumina Infinium EPIC array analysis, and methylation was assessed blinded to histopathological and clinical data. CpG sites whose state of methylation correlated with lesion grade were assessed (Spearman correlation), and a weighted methylation score was calculated comparing normal to CIN3. Validation of the top selected genes was performed in an independent cohort (100 normal, 50 CIN1, 50 CIN2, 50 CIN3 and 8 cervical cancers) of new patients, referred for colposcopic examination at three hospitals, using targeted DNA methylation Illumina amplicon sequencing. The relationship between a combined weighted marker score and progression from normal through precancerous lesions and cervical cancer was compared using one‐way ANOVA. Our analyses revealed 7,715 CpGs whose methylation level correlated with progression (from normal to CIN1, CIN2 and CIN3), with a significant trend of increased methylation with lesion grade. We shortlisted a bigenic (hyaluronan synthase 1, HAS1 and ATPase phospholipid transporting 10A, ATP10A corresponding to cg03419058 and cg13944175 sites) marker set; r = 0.55, p < 0.0001. Validation of the four most discriminating genes (CA10, DPP10, FMN2 and HAS1) showed a significant correlation between methylation levels and disease progression (p‐value < 2.2 × 10−16, adjusted R2 = 0.952). Translational research of the identified genes to future clinical applications is warranted.

Comparative performance evaluation of different HPV tests and triaging strategies using self‐samples and feasibility assessment of thermal ablation in ‘colposcopy and treat’ approach: A population‐based study in rural China

Human papillomavirus (HPV) test, self‐sampling and thermal ablation for cervical intraepithelial neoplasia (CIN) have been developed separately to increase screening coverage and treatment compliance of cervical cancer screening programmes. A large‐scale study in rural China screened 9,526 women with their combinations to explore the optimal cervical cancer‐screening cascade in the real‐world. Participants received careHPV and polymerase chain reaction (PCR) HPV tests on self‐collected samples. Women positive on either HPV test underwent colposcopy, biopsy and thermal ablation in a single visit. Samples positive on either HPV test were retested for genotyping. Absolute and relative performance of HPV tests, triage strategies, ‘colposcopy and thermal ablation’ approach were statistically evaluated. PCR HPV test detected 33.3% more CIN grade two or worse (CIN2+) at a cost of 28.1% more colposcopies compared to careHPV. Sensitivities of PCR HPV and careHPV tests to detect CIN2+ were 96.7 and 72.5%. Specificities for the same disease outcome were 82.1 and 86.0%. Triaging HPV‐positive women with HPV16/18 genotyping considerably improved the positive predictive value for CIN2+ (4.8–5.0 to 18.2–19.2%). Ninety‐six women positive on HPV and having abnormal colposcopy were eligible for thermal ablation and all accepted same‐day treatment, contributing to 64.6% being treated appropriately (CIN1+ on histopathology), which reached up to 84.8% among women positive on HPV 16/18 triage. No serious side‐effects/complications were reported. The combination of PCR HPV test followed by HPV 16/18 triaging on self‐collected samples and colposcopy of triage positive women followed by immediate thermal ablation might be the appropriate screening cascade for rural China.

Primary HPV testing with cytology versus cytology alone in cervical screening—A prospective randomized controlled trial with two rounds of screening in a Chinese population

We conducted a prospective randomized controlled trial with two screening rounds to evaluate the effectiveness of combining HPV testing with liquid‐based cytology (LBC) as a co‐test, compared to LBC only in cervical cancer screening of a Chinese population. First, 15,955 women aged 30–60 were randomized at a 1:1 ratio into an intervention group (Digene Hybrid Capture 2 HPV test with LBC) and a control group (LBC alone). Women in the intervention group would be referred for colposcopy and biopsy immediately if they were found to have high‐risk HPV regardless of cytology results. The detection of cervical intraepithelial neoplasia grade 2 or above (CIN2+) lesions was significantly higher in the intervention group compared to the control (0.95% vs. 0.38%, OR 2.50, 95% CI 1.65–3.88). At the subsequent round of screening approximately 36 months later, CIN2+ detection was significantly lower in the intervention group (0.08% vs. 0.35%, OR 0.23, 95% CI 0.08–0.57). Over the two rounds of screening, the total detection of CIN2+ was higher in the intervention group (1.01% vs. 0.66%, OR 1.53, 95% CI 1.09–2.19). There was a fourfold increase (10.6% vs. 2.4%, p < 0.001) in the number of colposcopies performed in the intervention arm. Adding a high‐risk HPV test to cytology for primary cervical screening led to earlier detection of clinically significant preinvasive lesions, resulting in a reduced detection of CIN2+ lesions in subsequent rounds and an increased rate of colposcopy.

Human papillomavirus types in cervical dysplasia among young HPV‐vaccinated women: Population‐based nested case–control study

Human papillomavirus (HPV) vaccines protect against infections with the most oncogenic HPV types, cervical intraepithelial neoplasia (CIN) and cervical cancer. We investigated whether development of cervical intraepithelial neoplasia (CIN) lesions in HPV‐vaccinated women is associated with vaccine‐targeted HPV types or not. Linkage of the Swedish vaccination and cervical screening registries identified all females born 1980–2000 who had been HPV vaccinated before December 31, 2014 (n = 305,320) and had attended cervical screening in 2006–2018 (n = 79,491). We further selected women HPV vaccinated below 17 years of age and screened in the capital region (n = 5,874). Among those, 125 developed CIN and had a cervical cryopreserved sample available (42.5% of all eligible CIN cases). After 1:2 matching to disease‐free HPV vaccinated controls (n = 242), samples were analyzed for HPV DNA and associations between HPV type and CIN diagnosis were estimated with conditional logistic regression. Vaccine‐targeted HPV types were rare among both CIN cases (2.4% HPV16, 0.8% HPV18) and their matched controls (0.4% HPV16 and 18). No woman had HPV6 or 11. The CIN lesions were associated with the nonvaccine HPV types 31, 33, 42, 45, 51, 52, 56, 59 and 66. CIN lesions among young HPV vaccinated women are mostly attributable to infection with nonvaccine HPV types. The phenomenon may be important for surveillance and design of cervical cancer control strategies.

Nonbreast cancer incidence, treatment received and outcomes: Are there differences in breast screening attendees versus nonattendees?

While reductions in breast cancer mortality have been evident since the introduction of population‐based breast screening in women aged 50–74 years, participation in cancer screening programs can be influenced by several factors, including health system and those related to the individual. In our study, we compared cancer incidence and mortality for several cancer types other than breast cancer, noncancer mortality and patterns of treatment amongst women who did and did not participate in mammography screening. All women aged 50–65 years enrolled on the Queensland Electoral Roll in 2000 were included. The study population was then linked to records from the population‐based breast screening program and private fee‐for‐service screening options to establish screened and unscreened cohorts. Diagnostic details for selected cancers and cause of death were obtained from the Queensland Oncology Repository. We calculated incidence rate ratios and hazard ratios comparing screened and unscreened cohorts. Among screened compared to unscreened women, we found a lower incidence of cancers of the lung, cervix, head and neck and esophagus and an increase in colorectal cancers. Cancer mortality (excluding breast cancer) was 35% lower among screened compared to unscreened women and they were also about 23% less likely to be diagnosed with distant disease. Screened compared to unscreened women were more likely to receive surgery and less likely to receive no treatment. Our study adds further to the population data examining outcomes among women participating in mammography screening.

Baseline findings and safety of infrequent vs. frequent screening of human papillomavirus vaccinated women

Less frequent cervical cancer screening in human papillomavirus (HPV) vaccinated birth cohorts could produce considerable savings without increasing cervical cancer incidence and loss of life‐years. We report here the baseline findings and interim results of safety and accuracy of infrequent screening among HPV16/18 vaccinated females. The entire 1992–1994 birth‐cohorts (30,139 females) were invited to a community‐randomized HPV16/18‐vaccination trial. A total of 9,482 female trial participants received HPV16/18‐vaccination in 2007–2009 at age of 13–15. At age 22, 4,273 (45%) of these females consented to attend a randomized trial on frequent (ages 22/25/28; Arm 1: 2,073 females) vs. infrequent screening (age 28; Arm 2: 2,200 females) in 2014–2017. Females (1,329), who had got HPV16/18 vaccination at age 18 comprised the safety Arm 3. Baseline prevalence and incidence of HPV16/18 and other high‐risk HPV types were: 0.5% (53/1,000 follow‐up years, 104) and 25% (2,530/104) in the frequently screened Arm 1; 0.2% (23/104) and 24% (2,413/104) in the infrequently screened Arm 2; and 3.1% (304/104) and 23% (2,284/104) in the safety Arm 3. Corresponding prevalence of HSIL/ASC‐H and of any abnormal cytological findings were: 0.3 and 4.2% (Arm 1), 0.4 and 5.3% (Arm 2) and 0.3 and 4.7% (Arm 3). Equally rare HSIL/CIN3 findings in the infrequently screened safety Arm A3 (0.4%) and in the frequently screened Arm 1 (0.4%) indicate no safety concerns on infrequent screening despite the up to 10 times higher HPV16/18 baseline prevalence and incidence in the former.

Decreased local immune response and retained HPV gene expression during chemoradiotherapy are associated with treatment resistance and death from cervical cancer

More than one‐third of patients with locally advanced cervical cancer do not respond to chemoradiation therapy (CRT). We aimed to characterize the transcriptional landscape of paired human cervical tumors before and during CRT in order to gain insight into the evolution of treatment response and to elucidate mechanisms of treatment resistance. We prospectively collected cervical tumor biopsies from 115 patients both before and 3 weeks into CRT. RNA‐sequencing, Gene Set Enrichment Analysis and HPV gene expression were performed on 20 paired samples that had adequate neoplastic tissue mid‐treatment. Tumors from patients with no evidence of disease (NED) at last follow‐up had enrichment in pathways related to the immune response both pretreatment and mid‐treatment, while tumors from patients dead of disease (DOD) demonstrated enrichment in biosynthetic and mitotic pathways but not in immune‐related pathways. Patients DOD had decreased expression of T‐cell and cytolytic genes and increased expression of PD‐L2 mid‐treatment compared to patients NED. Histological and immunohistochemical analysis revealed a decrease in tumor‐associated lymphocytes (TAL) during CRT in all patients but tumors from patients DOD had a significantly more pronounced decrease in TALs and CD8+ cells mid‐treatment, which was validated in a larger mid‐treatment cohort. Finally, patients DOD retained more HPV E6/E7 gene expression during CRT and this was associated with increased expression of genes driving mitosis, which was corroborated in vitro. Our results suggest that decreased local immune response and retained HPV gene expression may be acting together to promote treatment resistance during CRT in patients with cervical cancer.

Highly immunosuppressive HLADRhi regulatory T cells are associated with unfavorable outcomes in cervical squamous cell carcinoma

Regulatory T cells (Tregs) are crucial for the maintenance of peripheral tolerance, but they also limit beneficial responses through cancer‐induced immunoediting. The roles of Treg subsets in cervical squamous cell carcinoma (CSCC) are currently unknown. Here, we aimed to perform an extensive study with an increased resolution of the Treg compartment in the peripheral blood and tumor tissues of CSCC patients. We first identified that an HLADRhi Treg population in the peripheral blood was significantly increased in CSCC patients compared to precancer patients and healthy donors. We found that HLADRhi Tregs express high levels of a panel of inhibition and activation markers and the TCR‐responsive transcription factors BATF and IRF4. However, this Treg subset showed reduced calcium influx after TCR crosslinking. In addition, HLADRhi Tregs are highly proliferative and vulnerable to apoptosis. Further studies demonstrated that the HLADRhi Tregs display high levels of suppressive activity. Quantitative multiplexed immunohistochemistry revealed that an increase in the number of tumor‐infiltrating HLADRhi Tregs is associated with unfavorable classical risk parameters of advanced disease stage and stromal invasion. Context‐based quantification revealed that a high frequency of stromal HLADRhi Tregs in patients is significantly associated with worse progression‐free survival. In the current study, we characterized a population of highly activated and immunosuppressive HLADRhi Tregs in CSCC patients. An increased HLADRhi Treg frequency may be a potential biomarker to stratify CSCC patients and evaluate therapeutic efficacies in personalized immuno‐oncology studies.

Feasibility of a community‐based cervical cancer screening with “test and treat” strategy using self‐sample for an HPV test: Experience from rural Cameroon, Africa

To achieve higher coverage and effectiveness in limited‐resource settings, World Health Organization (WHO) guidelines for cervical cancer prevention recommend a screen‐and‐treat strategy with high‐risk human papillomavirus (HPV) testing. We piloted a real‐word project to examine the feasibility of this approach in rural Cameroon. Nurses from the Women's Health Program (WHP) of the Cameroon Baptist Convention Health Services (CBCHS) educated women in remote villages on cervical cancer prevention. At a follow‐up visit, they explained to nonpregnant women aged 30–65 how to self‐collect vaginal specimens for HPV testing with the careHPV assay. The cytobrush specimens were transported in coolers to a CBCHS laboratory for analysis. The nurses returned to villages to inform women of their results, examined HPV‐positive women in the primary health centers (PHCs) using visual inspection with acetic acid and Lugol's iodine (VIA/VILI) enhanced by digital cervicography (DC) to guide treatment. Of the 1,270 eligible women screened (mean age: 44.7 years), 196 (15.4%) were HPV‐positive, of whom 185 (94.4%) were examined, 16 (8.6%) were VIA/VILI‐positive, 8 (4.3%) were VIA/VILI‐inadequate, one (0.5%) was VIA/VILI‐uncertain and 161 (87.0%) were treated with thermal ablation. One woman had LEEP, and another woman with invasive cancer was treated at a referral facility. The cytobrushes broke off in the vaginas of two women (removed in the village) and in the bladder of another (surgically removed). Community‐based cervical cancer screening with self‐collected specimens for HPV testing is feasible in rural Cameroon. Education on the proper sampling procedure and follow‐up of women who are HPV‐positive are essential.

Effects of the antifungal agent ciclopirox in HPV‐positive cancer cells: Repression of viral E6/E7 oncogene expression and induction of senescence and apoptosis

The malignant growth of human papillomavirus (HPV)‐positive cancer cells is dependent on the continuous expression of the viral E6/E7 oncogenes. Here, we examined the effects of iron deprivation on the phenotype of HPV‐positive cervical cancer cells. We found that iron chelators, such as the topical antifungal agent ciclopirox (CPX), strongly repress HPV E6/E7 oncogene expression, both at the transcript and protein level. CPX efficiently blocks the proliferation of HPV‐positive cancer cells by inducing cellular senescence. Although active mTOR signaling is considered to be critical for the cellular senescence response towards a variety of prosenescent agents, CPX‐induced senescence occurs under conditions of severely impaired mTOR signaling. Prolonged CPX treatment leads to p53‐independent Caspase‐3/7 activation and induction of apoptosis. CPX also eliminates HPV‐positive cancer cells under hypoxic conditions through induction of apoptosis. Taken together, these results show that iron deprivation exerts profound antiviral and antiproliferative effects in HPV‐positive cancer cells and suggest that iron chelators, such as CPX, possess therapeutic potential as HPV‐inhibitory, prosenescent and proapoptotic agents in both normoxic and hypoxic environments.

Epidemiological evidence that common HPV types may be common because of their ability to evade immune surveillance: Results from the Women's Interagency HIV study

Infection by human papillomavirus (HPV) type 16, the most oncogenic HPV type, was found to be the least affected by HIV‐status and CD4 count of any of the approximately 13 oncogenic HPV types. This relative independence from host immune status has been interpreted as evidence that HPV16 may have an innate ability to avoid the effects of immunosurveillance. However, the impact of immune status on other individual HPV types has not been carefully assessed. We studied type‐specific HPV infection in a cohort of 2,470 HIV‐positive (HIV[+]) and 895 HIV‐negative (HIV[−]) women. Semi‐annually collected cervicovaginal lavages were tested for >40 HPV types. HPV type‐specific prevalence ratios (PRs), incidence and clearance hazard ratios (HRs), were calculated by contrasting HPV types detected in HIV[+] women with CD4 < 200 to HIV[−] women. HPV71 and HPV16 prevalence had the weakest associations with HIV‐status/CD4 count of any HPV, according to PRs. No correlations between PRs and HPV phylogeny or oncogenicity were observed. Instead, higher HPV type‐specific prevalence in HIV[−] women correlated with lower PRs (ρ = −0.59; p = 0.0001). An alternative (quadratic model) statistical approach (PHIV+ = a*PHIV− + b*PHIV−2; R2 = 0.894) found similar associations (p = 0.0005). In summary, the most prevalent HPV types in HIV[−] women were the types most independent from host immune status. These results suggest that common HPV types in HIV[−] women may have a greater ability to avoid immune surveillance than other types, which may help explain why they are common.

Effects of exposure to polycyclic aromatic hydrocarbons combined with high‐risk human papillomavirus infection on cervical intraepithelial neoplasia: A population study in Shanxi Province, China

High‐risk human papillomavirus (HR‐HPV) infection is a major etiological agent in the progression of cervical intraepithelial neoplasia (CIN) and cervical cancer. Polycyclic aromatic hydrocarbons (PAHs) are carcinogenic pollutants that exist widely in the environment. We hypothesized that PAHs exposure was related to the progression of cervical cancer, and could increase the effect of HR‐HPV on CIN. We investigated the effects of PAHs exposure combined with HR‐HPV infection on CIN in community population in Shanxi Province, China. A total of 2,285 women were enrolled into the study. HR‐HPV genotypes were detected by flow‐through hybridization technology. 1‐hydroxypyrene (1‐OHP) was detected by high‐performance liquid chromatography. The top three HR‐HPV genotypes were 16, 58 and 52 in turn. With unconditional logistic regression analysis, we found that HR‐HPV infection (adjusted odds ratio [aOR] = 4.08, 95% confidence interval [CI]: 3.00–5.54), HPV16 infection (aOR = 4.71, 95% CI: 3.39–6.53), HPV58 infection (aOR = 2.29, 95% CI: 1.41–3.73) and PAHs high exposure (aOR = 2.57, 95% CI: 1.82–3.62) increased the risk of CIN2/3, showing an increasing trend (p < 0.001) with the severity of cervical lesions. Compared to Q1 (<0.06 μmol/molCr) levels of 1‐OHP, women with Q4 (>0.11 μmol/molCr) had a higher risk for CIN2/3 (aOR = 7.68, 95% CI: 4.83–12.22). Additionally, we observed that there was a synergic effect between high exposure to PAHs and HR‐HPV infection in CIN2/3. Furthermore, the results from the generalized multifactor dimensionality reduction model showed that there were joint interactions of PAHs, HPV16, HPV58 and HPV52 on the risk of CIN2/3. Our study revealed that high exposure to PAHs could increase the risk for CIN, and it posed stronger risk when combined with HR‐HPV infection.

Human papillomavirus genotypes in women with invasive cervical cancer with and without human immunodeficiency virus infection in Botswana

Cervical cancer remains a significant cause of morbidity and mortality in women worldwide and is the leading cause of cancer‐related death in Botswana. It is well established that women with HIV have a higher risk of persistent HPV infection leading to cervical cancer. We assessed HPV prevalence and genotype distribution in 126 tissue specimens from confirmed invasive cervical cancer cases using Abbott real‐time PCR assay. Overall, 88 (69.8%) women were HIV‐infected. Fifty‐seven (64.8%) of the HIV‐infected women had a baseline CD4+ count ≥350 cells/μl, and 82 (93.2%) were on antiretroviral therapy at the time of cervical cancer diagnosis. The median age of HIV‐infected patients was significantly younger than that of HIV‐uninfected patients (p < 0.001). HPV DNA was detected in all of 126 (100%) of tissues analyzed in our study. The HPV genotypes identified included the HPV‐16 (75.4%), HPV‐18 (28.6%) and other high‐risk (hr) HPV genotypes (16.7%). HIV infection was positively associated with the presence of the HPV‐16 genotype (p = 0.036), but not with HPV‐18 or with other high‐risk (hr)‐HPV genotypes. Thirty‐three percent of the patients had multiple hr‐HPV genotypes, with higher rates in HIV‐infected women. These results highlight the importance and potential impact of large‐scale HPV vaccination programs covering HPV‐16 and HPV‐18 genotypes in countries like Botswana with high burden of HIV infection.

HPV73 a nonvaccine type causes cervical cancer

HPV73 is classified as possibly oncogenic. It is neither routinely evaluated in HPV screening, nor covered by any of the prophylactic vaccines. We sought to investigate the carcinogenic characteristics of HPV73. Molecular studies were performed on eight cervix cancer biopsy specimens containing HPV73 from a cross‐sectional cancer cohort of 590 women referred to the National Cancer Institute in Rio de Janeiro, Brazil. Transcriptional activity of HPV73 was evaluated by detection of spliced transcripts of E6/E6* and E1^E4 in cDNA created from RNA isolated from fresh tissue. Disruption of viral E1 and E2 genes in the tumor DNA was assessed by overlapping PCR amplification. Evaluation of viral integration was performed using a customized capture panel and next‐generation sequencing, and an in‐house bioinformatic pipeline. HPV73 E6/E6* transcripts were found in 7/7 specimens with available RNA, and three also had HPV73 E1^E4 transcripts. Disruption of E1 and E2 genes was observed in 4/8 specimens. Integration of HPV73 sequences into the cancer cell genomes was identified in all cervix cancer tissues. These results provide evidence that HPV73 is an oncogenic virus that can cause invasive cervix cancer. With current molecular screening and HPV vaccination, not all cervix cancers will be prevented.

Absolute risks of cervical precancer among women who fulfill exiting guidelines based on HPV and cytology cotesting

US guidelines recommend that most women older than 65 years cease cervical screening after two consecutive negative cotests (concurrent HPV and cytology tests) in the previous 10 years, with one in the last 5 years. However, this recommendation was based on expert opinion and modeling rather than empirical data on cancer risk. We therefore estimated the 5‐year risks of cervical precancer (cervical intraepithelial neoplasia grade 3 or adenocarcinomain situ[CIN3]) after one, two and three negative cotests among 346,760 women aged 55–64 years undergoing routine cotesting at Kaiser Permanente Northern California (2003–2015). Women with a history of excisional treatment or CIN2+ were excluded. No woman with one or more negative cotests was diagnosed with cancer during follow‐up. Five‐year risks of CIN3 after one, two, and three consecutive negative cotests were 0.034% (95% CI: 0.023%–0.046%), 0.041% (95% CI: 0.007%–0.076%) and 0.016% (95% CI: 0.000%–0.052%), respectively (ptrend< 0.001). These risks did not appreciably differ by a positive cotest result prior to the one, two or three negative cotest(s). Since CIN3 risks after one or more negative cotests were significantly below a proposed 0.12% CIN3+ risk threshold for a 5‐year screening interval, a longer screening interval in these women is justified. However, the choice of how many negative cotests provide sufficient safety against invasive cancer over a woman's remaining life represents a value judgment based on the harmsversusbenefits of continued screening. Ideally, this guideline should be informed by longer‐term follow‐up given that exiting is a long‐term decision.

Cervical adenocarcinoma in situ: Human papillomavirus types and incidence trends in five states, 2008–2015

Primary prevention through the use of human papillomavirus (HPV) vaccination is expected to impact both cervical intraepithelial neoplasia (CIN) and adenocarcinoma in situ (AIS). While CIN is well described, less is known about the epidemiology of AIS, a rare cervical precancer. We identified AIS and CIN grade 3 (CIN3) cases through population‐based surveillance, and analyzed data on HPV types and incidence trends overall, and among women screened for cervical cancer. From 2008 to 2015, 470 AIS and 6,587 CIN3 cases were identified. The median age of women with AIS was older than those with CIN3 (35 vs. 31 years; p < 0.01). HPV16 was the most frequently detected type in both AIS and CIN3 (57% in AIS; 58% in CIN3), whereas HPV18 was the second most common type in AIS and less common in CIN3 (38% vs. 5%; p < 0.01). AIS lesions were more likely than CIN3 lesions to be positive for high‐risk types targeted by the bivalent and quadrivalent vaccines (HPV16/18, 92% vs. 63%; p < 0.01), and 9‐valent vaccine (HPV16/18/31/33/45/52/58, 95% vs. 87%; p < 0.01). AIS incidence rates decreased significantly in the 21–24 year age group (annual percent change [APC] overall: −22.1%, 95% CI: −33.9 to −8.2; APC among screened: −16.1%, 95% CI: −28.8 to −1.2), but did not decrease significantly in any older age group. This report on the largest number of genotyped AIS cases to date suggests an important opportunity for vaccine prevention of AIS, and is the first to document a decline in AIS incidence rates among young women during the vaccine era.

HEBERSaVax immunotherapy combined with first‐line chemotherapy in advanced ovarian cancer: Phase II CENTAURO ‐4 trial results

Abstract VEGF‐driven angiogenesis fuels epithelial ovarian cancer progression, ascites, and poor prognosis. Current anti‐VEGF/chemotherapy combinations provide only transient benefits with notable toxicity. HEBERSaVax, a first‐in‐class VEGF‐targeting immunotherapy, combines recombinant VEGF‐A 121 with proprietary adjuvants to generate dual anti‐tumor effects: (1) neutralizing VEGF signaling via antibodies and (2) eliminating VEGF‐producing cells through cytotoxic T‐cell responses. We present results from the multicenter, open‐label CENTAURO 4 phase 2 trial evaluating two formulations of HEBERSaVax combined with carboplatin/paclitaxel in advanced epithelial ovarian cancer patients (unresectable or suboptimal debulked). Forty patients were randomized 1:1 to receive either: Group 1: Standard chemotherapy (carboplatin/paclitaxel) plus CIGB‐247 vaccine (800 μg antigen with 200 μg VSSP adjuvant) Group 2: The same chemotherapy regimen plus CIGB‐247 (800 μg antigen with 0.7 mg aluminum phosphate adjuvant). The primary endpoint was progression‐free survival. Secondary endpoints included objective response rate, overall survival, safety, and immune response results. HEBERSaVax exhibited excellent safety profiles and comparable immunogenicity with both adjuvant formulations. Vaccination‐related adverse events were limited to grade 1–2 toxicities. Long‐term outcomes showed promising clinical activity, with a median progression‐free survival of 18 months and a global median overall survival of 32.82 months at 6‐year follow‐up. No statistically significant differences emerged between the VSSP and aluminum phosphate adjuvant formulations for either safety or efficacy endpoints. These clinical outcomes and the vaccine's favorable toxicity profile position HEBERSaVax as a promising immunotherapeutic strategy for improving epithelial ovarian cancer management.

Global incidence, risk factors and trends of vulvar cancer: A country‐based analysis of cancer registries

AbstractVulvar cancer is an uncommon malignancy. Vulvar cancer alarmed the public health problem in terms of the cost of diagnostic and medical treatments and psychical health of females. Our study aims to provide a thorough analysis of the global disease burden, related risk factors and temporal incidence trends of vulvar cancer in population subgroups. Data from Global Cancer Observatory and the Cancer Incidence in Five Continents Plus were used for the vulvar cancer incidence. Age‐standardized rates (ASR) were used to depict the incidence of vulvar cancer. The 10‐year trend of incidence was assessed using joinpoint regression with average annual percentage change and 95% confidence intervals in various age groups, while its correlations with risk factors were investigated using linear regression. Higher ASR were found in Western Europe (2.4), Northern America (1.9), Northern Europe (1.9), Australia and New Zealand (1.8) and Eastern Africa (1.4). The associated risk factors of higher vulvar cancer incidence were gross domestic product per capita, Human Development Index, higher prevalence of smoking, alcohol drinking, unsafe sex and human immunodeficiency virus infection. The overall trend of vulvar cancer incidence was increasing. An increasing trend was found in older females while a mixed trend was observed in younger females. The disease burden of vulvar cancer follows a bimodal pattern according to its two histologic pathways, affecting women in both developed and developing regions. Smoking cessation, sex education and human papillomavirus vaccination programs should be promoted among the general population. Subsequent studies can be done to explore the reasons behind the increasing trend of vulvar cancer.

Accuracy of different triage strategies for human papillomavirus positivity in an Italian screening population

AbstractHow to manage human papillomavirus (HPV)‐positive women in cervical cancer screening remains debated. Our study compared different strategies to triage HPV positivity in a large cohort of women participating in a population HPV‐based screening program. Women were tested for HPV (Cobas 4800; Roche), and those positive were triaged with cytology; cytology‐positives were referred to colposcopy, while negatives were referred to 1‐year HPV retesting. All HPV‐positive women were also evaluated with p16/ki67 dual staining (Roche). All lesions found within 24 months of follow‐up were included in the analyses. Of the 70 146 women tested, 4757 (6.8%) were HPV‐positive. Of these, 1090 were cytology‐positive and were referred to colposcopy. Of the 2958 HPV‐positive/cytology‐negative women who presented at 1‐year retesting, 1752 (59.9%) still tested positive. Cumulatively, 532 CIN2+ (including 294 CIN3+) were found. The sensitivity of cytology, HPV16/18 and p16/ki67 as triage test for CIN3+ was 67.9%, 56.0% and 85.0%, respectively. The positive predictive value (PPV) for immediate colposcopy referral was 21.0%, 15.8% and 22.9%, respectively. Combining cytology with typing increased sensitivity to 83.9% and lowered PPV to 14.8%, while combining p16/ki67 and typing increased sensitivity to 91.1%, lowering the PPV to 15.9%. Women negative to p16/ki67 triage presented a cumulative 1‐year CIN3+ risk of about 1%. In conclusion, when triaging HPV positivity, p16/ki67 performed better than cytology with or without HPV16/18 genotyping. The strategies that included dual staining achieved sensitivity and low 1‐year risk for CIN3+ sufficiently high enough to permit considering extending the surveillance interval to 2 to 3 years for HPV‐positive/triage‐negative women.

Switching clinic‐based cervical cancer screening programs to human papillomavirus self‐sampling: A cost‐effectiveness analysis of vaccinated and unvaccinated Norwegian women

AbstractSeveral countries have implemented primary human papillomavirus (HPV) testing for cervical cancer screening. HPV testing enables home‐based, self‐collected sampling (self‐sampling), which provides similar diagnostic accuracy as clinician‐collected samples. We evaluated the impact and cost‐effectiveness of switching an entire organized screening program to primary HPV self‐sampling among cohorts of HPV vaccinated and unvaccinated Norwegian women. We conducted a model‐based analysis to project long‐term health and economic outcomes for birth cohorts with different HPV vaccine exposure, that is, preadolescent vaccination (2000‐ and 2008‐cohorts), multiage cohort vaccination (1991‐cohort) or no vaccination (1985‐cohort). We compared the cost‐effectiveness of switching current guidelines with clinician‐collected HPV testing to HPV self‐sampling for these cohorts and considered an additional 44 strategies involving either HPV self‐sampling or clinician‐collected HPV testing at different screening frequencies for the 2000‐ and 2008‐cohorts. Given Norwegian benchmarks for cost‐effectiveness, we considered a strategy with an additional cost per quality‐adjusted life‐year below $55 000 as cost‐effective. HPV self‐sampling strategies considerably reduced screening costs (ie, by 24%‐40% across cohorts and alternative strategies) and were more cost‐effective than clinician‐collected HPV testing. For cohorts offered preadolescent vaccination, cost‐effective strategies involved HPV self‐sampling three times (2000‐cohort) and twice (2008‐cohort) per lifetime. In conclusion, we found that switching from clinician‐collected to self‐collected HPV testing in cervical screening may be cost‐effective among both highly vaccinated and unvaccinated cohorts of Norwegian women.

Clinical performance of methylation as a biomarker for cervical carcinoma in situ and cancer diagnosis: A worldwide study

AbstractThe shift towards primary human papillomavirus (HPV)‐based screening has necessitated the search for a secondary triage test that provides sufficient sensitivity to detect high‐grade cervical intraepithelial neoplasia (CIN) and cancer, but also brings an improved specificity to avoid unnecessary clinical work and colposcopy referrals. We evaluated the performance of the previously described DNA‐methylation test (S5) in detecting CIN3 and cancers from diverse geographic settings in high‐, medium‐ and low‐income countries, using the cut‐off of 0.80 and exploratory cut‐offs of 2.62 and 3.70. Assays were performed using exfoliated cervical specimens (n = 808) and formalin‐fixed biopsies (n = 166) from women diagnosed with cytology‐negative results (n = 220), CIN3 (n = 204) and cancer stages I (n = 245), II (n = 249), III (n = 28) and IV (n = 22). Methylation increased proportionally with disease severity (Cuzick test for trend, P < .0001). S5 accurately separated women with negative‐histology from CIN3 or cancer (P < .0001). At the 0.80 cut‐off, 543/544 cancers were correctly identified as S5 positive (99.81%). At cut‐off 3.70, S5 showed a sensitivity of 95.77% with improved specificity. The S5 odds ratios of women negative for cervical disease vs CIN3+ were significantly higher than for HPV16/18 genotyping at all cut‐offs (all P < .0001). At S5 cut‐off 0.80, 96.15% of consistently high‐risk human papillomavirus (hrHPV)‐negative cancers (tested with multiple hrHPV‐genotyping assay) were positive by S5. These cancers may have been missed in current primary hrHPV‐screening programmes. The S5 test can accurately detect CIN3 and malignancy irrespective of geographic context and setting. The test can be used as a screening and triage tool. Adjustment of the S5 cut‐off can be performed considering the relative importance given to sensitivity vs specificity.

Elimination of cervical cancer in Tanzania: Modelled analysis of elimination in the context of endemic HIV infection and active HIV control

AbstractThe World Health Organisation (WHO) has launched a strategic initiative for cervical cancer (CC) elimination which involves scaling up three interventions: human papillomavirus (HPV) vaccination, twice‐lifetime HPV‐screening screening and pre‐cancer/cancer treatment by 2030. CC is challenging to control in countries with endemic human immunodeficiency virus (HIV), as women living with HIV (WLHIV) are at elevated risk of HPV infection, persistence and progression. This analysis estimated the impact of the elimination interventions on CC incidence and mortality but additionally considered more intensive screening for WLHIV, using Tanzania as an example. A dynamic HIV/HPV model was used to simulate the elimination strategy for vaccination, screening and pre‐cancer/cancer treatment, with 3‐yearly HPV‐screening in WLHIV starting at age 25 years, in the context of sustained HIV control in Tanzania from 2020 to 2119. Without vaccination or HPV screening, CC incidence rates per 100 000 women are predicted to fall from 58.0 in 2020 to 41.6 (range: 39.1‐44.7) in 2119, due to existing HIV control. HPV vaccination and twice‐lifetime HPV‐screening for the general population and 3‐yearly screening for WLHIV, would reduce CC incidence to 1.3 (range: 1.3‐2.5) by 2119, with elimination (<4/100 000) in 2076 (range: 2076‐2092). CC mortality rates per 100 000 women are predicted to reach 1.1 (range: 1.1‐2.1) with further reductions contingent on increased CC treatment access. Vaccination and 3‐yearly HPV‐screening for WLHIV is predicted to achieve elimination in the subgroup of WLHIV potentially as early as 2061 (range: 2061‐2078), with a 2119 CC incidence rate of 1.7 (range: 1.7‐3.3). Scaling‐up vaccination and HPV‐screening will substantially reduce CC incidence in Tanzania, with elimination predicted within a century. Three‐yearly HPV‐screening and HPV vaccination, at high coverage rates, would facilitate CC elimination among WLHIV, and thus accelerate elimination in the overall population.

Reply to: Comments on cumulative risk of cervical intraepithelial neoplasia for women with normal cytology but positive for human papillomavirus: Systematic review and meta‐analysis

Comments on “Cumulative risk of cervical intraepithelial neoplasia for women with normal cytology but positive for human papillomavirus: Systematic review and meta‐analysis”

Older women testing positive forHPV16/18 on cervical screening and risk of high‐grade cervical abnormality

AbstractIn Australia's HPV‐based cervical screening program, we previously showed that risk of histological high‐grade abnormality at 1 year post screening decreased with age in women with oncogenic HPV. In this study, we followed 878 HPV16/18 positive women aged 55 years and over for up to 3 years post screening test, to determine the proportion with histological high‐grade abnormality (HGA, incorporating high‐grade squamous intraepithelial abnormality (HSIL), adenocarcinoma in situ (AIS), squamous cell carcinoma (SCC) and adenocarcinoma) and to correlate risk of HGA with liquid‐based cytology result and with prior screening history. HGA was detected in 7.8% at 1 year and 10.0% at 3 years, with no significant difference (P = .136), despite the number of women with follow‐up information significantly increasing from 82.9% to 91.0% (P < .0001). The proportion of HPV16/18 positive women with HGA at 3 years was highest in those with an HSIL cytology result (79.0%) and lowest in those with negative cytology (6.2%). Women with an adequate screening history had fewer HGA than such women with inadequate prior screening (6.6% vs 16.0%,P = .001) or with a history of an abnormality (6.6% vs 14.4%,P = .001). HPV16/18 infection in women over 55 years may have a different natural history from that in younger women, in whom HGA are more common after HPV16/18 detection. In HPV‐based cervical screening programs, management algorithms for screen‐detected abnormalities based on risk stratification should include factors such as age, screening history and index cytology result, so that women receive appropriate investigation and follow‐up.

Trends and future projections of cervical cancer‐related outcomes in Japan: What happens if the HPV vaccine program is not implemented?

AbstractContrary to other developed countries, in Japan, recent years have seen increases in cervical cancer incidence and mortality among young people. However, the human papillomavirus (HPV) vaccine program, a key measure for avoiding cervical cancer, has been virtually suspended. Temporal changes in cervical cancer profiles in this unique situation have not been fully investigated epidemiologically. Our study aimed to determine the current status and future trends of the incidence and mortality of cervical cancer and precancerous lesions in Japan. Mortality rates of cervical cancer during 1975 to 2016 and incidence rates of cervical cancer and cervical intraepithelial neoplasia (CIN) 3 during 1975 to 2013 were examined using vital statistics and population‐based cancer registry data in Japan. Bayesian age‐period‐cohort analyses were performed to analyze temporal changes of the three cervical cancer‐related outcomes. We also calculated projections to 2028 for the three outcomes, assuming that HPV vaccination coverage and screening rates in Japan would be maintained at the current level after the resumption of the national vaccination program. The risk of occurrence of the three outcomes showed similar changes by birth cohort, peaking in the mid‐1890s to 1900s birth cohorts, declining sharply in the 1940s birth cohort, and persistently increasing in the 1950s and later birth cohorts. Projections to 2028 show increases in cervical cancer incidence and mortality in the 30 to 69 age group, with a particular increase in CIN3 incidence in the 25 to 49 age group, if HPV vaccine programs and screening are not effectively implemented. These findings revealed an increasing cervical disease burden among reproductive age females in Japan.

Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen‐positive women: results from the ESTAMPA study

AbstractVIA is recommended for triage of HPV‐positive women attending cervical screening. In the multicentric ESTAMPA study, VIA performance for detection of cervical intraepithelial neoplasia grade 3 or worse (CIN3+) among HPV‐positive women was evaluated. Women aged 30‐64 years were screened with HPV testing and cytology and referred to colposcopy if either test was positive. At colposcopy visit, study‐trained midwives/nurses/GPs performed VIA ahead of colposcopy. VIA was considered positive if acetowhite lesions were observed in or close to the transformation zone. Ablative treatment eligibility was assessed for VIA positives. Performance indicators were estimated. Three thousand one hundred and forty‐two HPV‐positive women were included. Sensitivity for CIN3+ was 85.9% (95% CI 81.2‐89.5) among women <50 years and, although not significant, slightly lower in women 50+ (78.0%, 95% CI 65.9‐86.6). Overall specificity was 58.6% (95% CI 56.7‐60.5) and was significantly higher among women 50+ (70.3%, 95% CI 66.8‐73.5) compared to women <50 (54.3%, 95% CI 52.1‐56.5). VIA positivity was lower among women 50+ (35.2%, 95% CI 31.9‐38.6) compared to women <50 (53.2, 95% CI 51.1‐55.2). Overall eligibility for ablative treatment was 74.5% and did not differ by age. VIA sensitivity, specificity, and positivity, and ablative treatment eligibility varied highly by provider (ranges: 25%‐95.4%, 44.9%‐94.4%, 8.2%‐65.3%, 0%‐98.7%, respectively). VIA sensitivity for cervical precancer detection among HPV‐positive women performed by trained providers was high with an important reduction in referral rates. However, scaling‐up HPV screening triaged by VIA will be challenging due to the high variability of VIA performance and providers' need for training and supervision.

Experiences with thermal ablation for cervical precancer treatment after self‐collection HPV‐based screening in the ASPIRE Mayuge randomized trial

AbstractCervical cancer remains a significant public health burden in low‐resourced countries. Thus, the WHO prioritized cervix screening, and recently recommended thermal ablation treatment for cervical precancer. However, there is limited information on side effects during treatment and recovery, and acceptability among those treated. The ASPIRE Mayuge trial recruited women to participate in self‐collection cervix screening between 2019 and 2020 (N = 2019). Screen‐positive women (N = 531, 26.3%) were referred for visual inspection with acetic acid and thermal ablation treatment, per Uganda Ministry of Health recommendations; 71.2% of those referred attended follow‐up. Six months post‐screening, a subset of trial participants were recontacted. Those who received thermal ablation completed a survey assessing side effects during and after the procedure, and willingness to recommend the treatment to others. We summarized the results to describe the side effects and acceptability of thermal ablation treatment. Of 2019 participants, 349 (17%) received thermal ablation. A subset of 135 completed the follow‐up survey, where 90% reported pain during treatment; however, intensity and duration were low. Over a third of women reported problems with recovery for reasons including pain, discharge and bleeding. Regardless, 98% reported they would recommend the treatment to others. The use of thermal ablation to treat cervical precancer appears to be highly acceptable in this population. While many women reported side effects during the procedure and recovery, the majority said they would recommend the treatment to others. However, given the substantial proportion who reported problems with recovery, efforts should be made to provide additional resources to women after receiving thermal ablation treatment for cervical precancer.

Anticancer effect of a pyrrole‐imidazole polyamide‐triphenylphosphonium conjugate selectively targeting a common mitochondrial DNA cancer risk variant in cervical cancer cells

AbstractCervical cancer remains a major threat to women's health, especially in countries with limited medical resources, and new drugs are needed to improve patient survival and minimize adverse effects. Here, we examine the effects of a triphenylphosphonium (TPP)‐conjugated pyrrole‐imidazole polyamide (CCC‐h1005) targeting the common homoplasmic mitochondrial DNA (mtDNA) cancer risk variant (ATP6 8860A>G) on the survival of cervical cancer cell lines, cisplatin‐resistant HeLa cells and patient‐derived cervical clear cell carcinoma cells as models of cervical cancer treatment. We found that CCC‐h1005 induced death in these cells and suppressed the growth of xenografted HeLa tumors with no severe adverse effects. These results suggest that PIP‐TPP designed to target mtDNA cancer risk variants can be used to treat many cervical cancers harboring high copies of the target variant, providing a foundation for clinical trials of this class of molecules for treating cervical cancer and other types of cancers.

Clinical presentation, diagnosis and management of therapy‐related hematological disorders in women with epithelial ovarian cancer treated with chemotherapy and poly‐ADP‐ribose polymerase inhibitors: A single‐center experience

AbstractWe investigated the occurrence and management of therapy‐related hematological disorders (tr‐HDs) in women with epithelial ovarian cancer (EOC) exposed to poly‐ADP‐ribose polymerase inhibitors (PARPi), after previous chemotherapy. We analyzed 130 consecutive EOC patients treated with PARPi at the European Institute of Oncology, Milan. In line with the literature, overall survival of the entire population was 37% at 5.5 years (89% were advanced stages). Cell blood counts were collected prior to start PARPi, at each new cycle and at monthly intervals. Patients displaying persistent and/or marked hematological abnormalities underwent bone marrow evaluation, with cytogenetic and molecular analysis. Nine patients (6,9%) developed tr‐HDs, after a median 22.8 months of PARPi exposure. Two patients died early and could not be treated. Two patients have no indication for active treatment and are presently under close hematological monitoring. Five patients underwent chemotherapy followed, in three cases, by allogeneic hematopoietic transplantation: three patients are in complete remission of their hematological and gynecological malignancies at 13, 19, and 25 months; the remaining two patients died due to progression of their hematological disease. We show the potential risk of hematological disorders in EOC patients treated with chemotherapy and prolonged PARPi therapy. In our series, tr‐HDs incidence was higher compared to recent reports in large series. Our observations suggest careful monitoring in order to conclusively define, on large series and prolonged follow‐up, the actual risk of tr‐HDs in patients under PARPi. Notably, prompt diagnosis of hematological abnormalities and appropriate management allow achievement of remission from severe hematological complications, at least in most patients.

HPV type‐specific trends in cervical precancers in the United States, 2008 to 2016

AbstractDeclines in cervical intraepithelial neoplasia grades 2 to 3 and adenocarcinoma in situ (CIN2+) observed among young women suggest impact from human papillomavirus (HPV) vaccination. To further evaluate vaccine impact including cross‐protection and type replacement, we described high‐risk (HR)‐HPV type‐specific cervical precancer incidence rates among women aged 20 to 39 years, 2008 to 2016. We analyzed cross‐sectional population‐based data on 18 344 cases of CIN2+ from a 5‐site surveillance system. Diagnostic specimens were tested for individual HPV types, including 14 HR‐HPV types (HPV16/18/31/33/35/39/45/51/52/56/58/59/66/68). We estimated age‐specific annual HR‐HPV type‐specific CIN2+ incidence per 100 000 screened women for individual types, vaccine HR‐HPV types (HPV16/18) and nonvaccine HR‐HPV types (non‐HPV16/18). We evaluated trends using average annual percent changes (AAPC) and 95% confidence intervals (CI), and estimated total declines by comparing 2015‐2016 to 2008‐2009 using incidence rate ratios. Among 20‐24‐year‐olds, HPV16/18‐CIN2+ declined from 2008 through 2016 (AAPC: −21.3%, 95% CI: −28.1%, −13.8%), whereas no trend was observed for non‐HPV16/18‐CIN2+ (AAPC: −1.8%, 95% CI: −8.1%, 4.9%). After 2010, CIN2+ among 20‐24‐year‐olds was more often caused by nonvaccine vs vaccine HR‐HPV types. No significant declining trends were observed in older age groups. In 2015‐2016 compared with 2008‐2009, HPV16‐CIN2+ declined 78%, HPV18‐CIN2+ 72% and HPV31‐CIN2+ 51% among 20‐24‐year‐olds; no increases were observed in type‐specific CIN2+ incidence. Among 25‐29‐year‐olds, HPV16‐CIN2+ declined 18%; CIN2+ attributed to seven nonvaccine types increased significantly. No significant declines were observed in older groups. Significant declines in HPV16/18‐CIN2+ in 20‐24‐year‐olds and HPV16‐CIN2+ in 25‐29‐year‐olds corroborate impact of HPV vaccination. A declining trend in HPV31‐CIN2+ is consistent with cross‐protection from vaccination.

Randomized multicenter phase II trial of prophylactic irradiation of para‐aortic lymph nodes in advanced cervical cancer according to tumor hypoxia: Korean Radiation Oncology Group (KROG 07‐01) study

AbstractWe conducted a prospective phase II study on whether extended‐field irradiation (EFI) confers survival benefits depending on hypoxic markers in locally advanced uterine cervical cancer (LAUCC). RNA‐seq was performed to identify immune and hypoxic gene signatures. A total of 288 patients were randomized to either EFI or pelvic radiotherapy (PRT). All patients completed chemoradiotherapy. Overall, significantly higher 5‐year para‐aortic recurrence free survival (PARFS) rate occurred in EFI (97.6%) than in PRT group (87.2%), with marginal tendency to improve disease‐free survival (DFS; 78% vs 70%, P = .066). Subgroup analyses were performed based on carbonic anhydrase 9 (CA9)‐only positive, CA9/hypoxia‐inducible factor (HIF) double positive and CA9 negative. In the CA9‐only positive, EFI successfully increased 5‐year PARFS (100% vs 76.4%, P = .010), resulting in significantly improved long‐term DFS (85.7% vs 54.7%, P = .023) compared to the PRT, while there was no such benefit of EFI in the CA9/HIFs double positive. RNA‐seq analysis identified distinct immunehigh subgroup with negative correlation with hypoxia gene signatures (R = −.37, P < .01), which showed a higher 5‐year DFS than the immunelow (P = .032). Hypoxia‐related genes were upregulated in the CA9/HIFs double positive compared to CA9 negative (P < .05). Only 17.4% of patients in CA9‐negative group showed immunelow signatures, while 40.0% of patients in the double‐positive group exhibited immunelow signatures. In conclusion, EFI improved PARFS significantly in all patients, but therapeutic efficacy of EFI in terms of improved DFS was solely observed in CA9‐only positive LAUCC, and not in CA9/HIFs double‐positive subgroup. RNA‐seq analysis suggested that hypoxia‐induced immunosuppression may be related to treatment resistance in LAUCC.

Different human papillomavirus types share early natural history transitions in immunocompetent women

AbstractNecessary stages of cervical carcinogenesis include acquisition of a carcinogenic human papillomavirus (HPV) type, persistence associated with the development of precancerous lesions, and invasion. Using prospective data from immunocompetent women in the Guanacaste HPV Natural History Study (NHS), the ASCUS‐LSIL Triage Study (ALTS) and the Costa Rica HPV Vaccine Trial (CVT), we compared the early natural history of HPV types to inform transition probabilities for health decision models. We excluded women with evidence of high‐grade cervical abnormalities at any point during follow‐up and restricted the analysis to incident infections in all women and prevalent infections in young women (aged <30 years). We used survival approaches accounting for interval‐censoring to estimate the time to clearance distribution for 20 529 HPV infections (64% were incident and 51% were carcinogenic). Time to clearance was similar across HPV types and risk classes (HPV16, HPV18/45, HPV31/33/35/52/58, HPV 39/51/56/59 and noncarcinogenic HPV types); and by age group (18‐29, 30‐44 and 45‐54 years), among carcinogenic and noncarcinogenic infections. Similar time to clearance across HPV types suggests that relative prevalence can predict relative incidence. We confirmed that there was a uniform linear association between incident and prevalent infections for all HPV types within each study cohort. In the absence of progression to precancer, we observed similar time to clearance for incident infections across HPV types and risk classes. A singular clearance function for incident HPV infections has important implications for the refinement of microsimulation models used to evaluate the cost‐effectiveness of novel prevention technologies.

Efficacy of ALA‐PDT in treating cervical low‐grade squamous intraepithelial lesions with high‐risk HPV patients: A multicentre randomized controlled trial

AbstractPersistent infection with high‐risk human papillomavirus (hrHPV) is a major cause of cervical cancer. Current management of low‐grade squamous intraepithelial lesions (LSIL) primarily involves monitoring, though some cases progress to cervical precancer or cancer, requiring timely intervention. This study aimed to evaluate the efficacy of 5‐aminolevulinic acid photodynamic therapy (ALA‐PDT) in treating cervical LSIL with hrHPV infection. A total of 155 women with LSIL and hrHPV infection were enrolled and randomly assigned to either the treatment group, which received six sessions of ALA‐PDT, or the control group, which underwent routine follow‐up. Outcomes were assessed at 6 and 12 months using hrHPV testing, cytology, colposcopy, and biopsy. Results showed that ALA‐PDT significantly improved lesion regression and hrHPV clearance rates at both 6 and 12 months. At 6 months, the lesion regression rate in the treatment group was 80.43% versus 56.10% in the control group (p = 0.0203), and the hrHPV clearance rate was 61.96% versus 29.27% (p = 0.0005). At 12 months, both rates remained significantly higher in the treatment group. Age was found to influence hrHPV clearance, with younger women (<45 years) showing significantly higher clearance rates. ALA‐PDT was well tolerated, with only minor side effects, such as localized pain and pruritus, reported. The study suggests that ALA‐PDT is a safe, effective, and non‐invasive treatment option for patients with cervical LSIL and hrHPV infection who require active intervention.

Triage performance and predictive value of the human gene methylation panel among women positive on self‐collected HPV test: Results from a prospective cohort study

AbstractTriaging of women positive for high‐risk human papillomavirus (hrHPV) on self‐collected samples requires a molecular reflex test to avoid recall for cytology or visual tests. We assessed triage performance and predictive value of human gene methylation panel (ZNF671/ASTN1/ITGA4/RXFP3/SOX17/DLX1) alone and with combination of HPV16/18 genotyping in a longitudinal screening study. Out of 9526 women at baseline, 1758 women positive for hrHPV on self‐collected samples followed up yearly were included in the current analysis. Satisfactory risk stratification to detect cervical intraepithelial neoplasia grade 2 or worse (CIN2+) was demonstrated by the methylation panel with an odds ratio (OR) of 11.3 among methylation‐positive women compared to methylation‐negative counterparts. Triaging with methylation panel reduced colposcopy referral rate by 67.2% with sensitivity and specificity of 83.0% and 69.9% to detect CIN2+. The corresponding values for the combining methylation and HPV 16/18 were 96.6% and 58.3%. The cumulative 3‐year incident CIN2+ risk was 6.8% (95% CI: 4.9%‐8.6%) for hrHPV positive women, which was reduced to 4.5% (95% CI: 2.7%‐6.3%) and 2.9% (95% CI: 1.2%‐4.5%) for women negative on methylation triaging alone and negative on the combined strategy. The corresponding risk for women positive for both methylation and HPV 16/18 reached 33.7% (95% CI: 19.0%‐45.8%). Our study demonstrated the satisfactory triage performance and predictive value of the methylation panel, especially in combination with HPV 16/18 genotyping. The substantially lower risk of CIN2+ among the triage negative women over the next 3 years suggests that the interval for repeat HPV test can be safely extended to at least 2 years.

Comments on: “Meta‐analysis of agreement/concordance statistics in studies comparing self‐ vs clinician‐collected samples for HPV testing in cervical cancer screening”

Chemotherapy as a double‐edged sword: Modulation of tumor‐associated cytokine and chemokine responses in ovarian cancer

Abstract Ovarian cancer (OC) is one of the most lethal gynecological malignancies, with high recurrence rates and chemoresistance posing significant challenges to effective treatment. Platinum‐based agents, such as cisplatin and carboplatin, along with taxanes, including paclitaxel and docetaxel, represent fundamental therapies for OC. However, the immunomodulatory effects of these agents on the tumor microenvironment are multifaceted and can be perceived as a double‐edged sword. Chemotherapeutics not only trigger cytotoxic effects but also influence the networks of pro‐ and anti‐tumor cytokines, playing a role in both treatment efficacy and resistance. We specifically examine cytokine‐mediated mechanisms underlying both platinum‐based and taxane‐based chemoresistance in OC. In this review, we comprehensively examine how platinum and taxane chemotherapy modulate cytokine signaling in OC, focusing on key mediators like interleukin (IL) 6, IL‐8, transforming growth factor‐beta, and C‐X‐C motif ligand 2 that drive survival pathways and chemoresistance. Interestingly, these agents might enhance anti‐tumor immunity via interferon‐gamma and IL‐12, revealing the potential for synergistic chemoimmunotherapy. This research provides valuable insights for addressing resistance and improving combination therapies through the analysis of the dual roles of chemotherapy in modulating cytokine dynamics in OC.

Association of aspirin and ibuprofen use with endometrial cancer risk in the PLCO dataset

Abstract Given the increasing incidence of endometrial cancer (EC) and the lack of improvement in survival rates, it is imperative to explore possible prevention methods. Studies on aspirin's effect on EC risk have been controversial; research on ibuprofen remains limited. We therefore aimed to investigate the relationship between aspirin and ibuprofen use and risk of EC through a cohort study. This analysis was based on the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, which recruited participants aged 55–74 years from 1993 to 2001, with follow‐up for cancer incidence continuing until December 31, 2009. A total of 42,394 women were enrolled in this analysis, and 678 cases of EC were diagnosed during a median follow‐up period of 12.0 years. Compared with an intake of <4 pills per month, the use of ibuprofen ≥30 pills per month significantly reduced EC risk (fully‐adjusted hazard ratio [HR], 0.75; 95% confidence interval [CI]: 0.58–0.98), particularly in participants with a history of cardiovascular disease (fully‐adjusted HR, 0.57; 95% CI: 0.37–0.87). No evidence was found for an association between aspirin and EC occurrence in the general population (fully‐adjusted HR, 0.98; 95% CI: 0.81–1.19), nor in specific subgroups. In conclusion, frequent ibuprofen use, unlike aspirin, was linked to reduced EC risk. This protective effect of ibuprofen was enhanced in women with a history of cardiovascular disease. Additional well‐designed, prospective research is needed to validate these findings and explore the underlying mechanisms.

Advances in the management of ovarian cancer liver metastasis

Abstract Liver metastasis represents a critical challenge in cancer progression, with particularly complex therapeutic implications. In ovarian cancer patients, ovarian cancer liver metastasis (OCLM) marks a distinct stage of disease progression that demands specialized diagnostic and therapeutic approaches. Despite its clinical significance, guidance for OCLM management remains notably absent in current clinical practice. This comprehensive review synthesizes recent advances in the management of OCLM, with special emphasis on a resectability‐based classification system.

Genetic landscape of Pakistani familial breast cancer patients using multigene panel testing

Abstract Pathogenic/likely pathogenic (P/LP) variants in high‐, moderate‐, and low‐penetrance genes account for approximately half of all familial breast cancer (BC) cases. In Pakistan, data on P/LP variants beyond BRCA1/2 remain limited. This study investigated the frequency and distribution of P/LP variants in Pakistani familial BC patients using a 14‐gene hereditary breast and ovarian cancer (HBOC) core panel. A total of 160 familial BC patients previously tested negative for protein‐truncating variants in BRCA1 , BRCA2 , CHEK2 , PALB2 , RAD51C , RAD51D , and TP53 using conventional methods were included. Next‐generation sequencing (NGS) was performed using the Illumina MiSeq platform, and all identified P/LP variants were validated by Sanger sequencing. Twenty‐four unique P/LP variants were identified across seven genes: BRCA1 ( n  = 10), BRCA2 ( n  = 6), TP53 ( n  = 3), CHEK2 ( n  = 2), PALB2 , ATM , and RAD51C ( n  = 1 each). Two recurrent BRCA1 variants, p.Gln169Ter and p.Val757Phefs*8, were identified in three patients each. NGS‐detected P/LP variants were identified in 18.1% (29/160) of patients. When combined with previous germline testing in the same cohort, the overall detection rate increased to 50.2% (132/263): BRCA1 (101/263; 38.4%), BRCA2 (22/263; 8.4%), TP53 (3/263; 1.1%), CHEK2 (2/263; 0.8%), PALB2 (2/263; 0.8%), ATM (1/263; 0.4%) and RAD51C (1/263; 0.4%). Among these, BRCA1/2 variants accounted for 93.2% (123/132) of all P/LP variants. Our findings demonstrate that P/LP variants are concentrated in a limited number of genes, with BRCA1/2 as the predominant contributors. We propose a cost‐effective, first‐tier genetic testing panel comprising seven genes ( ATM , BRCA1 , BRCA2 , CHEK2 , RAD51C , PALB2 , and TP53 ) for familial BC risk assessment in Pakistan.

Effects of levonorgestrel‐releasing intrauterine system on recurrence and fertility outcomes during assisted reproduction after complete remission of early endometrioid endometrial cancer and precancerous lesions: A retrospective cohort study

AbstractTo investigate the efficacy of the levonorgestrel‐releasing intrauterine system (LNG‐IUS) on recurrence and fertility outcomes during controlled ovarian stimulation (COS) in patients with early stage endometrioid endometrial carcinoma (EEC) and endometrial atypical hyperplasia (EAH) following successful fertility‐preserving treatment. We reviewed the patients with Grade 1 presumed Stage IA EEC or EAH who underwent in vitro fertilization and embryo transfer after successful fertility‐sparing treatment. A total of 176 women were enrolled in this study, undergoing 318 cycles of COS and 290 cycles of embryo transfer (ET). Twenty‐one percent (37/176) patients have an LNG‐IUS insertion during the initial ovarian stimulation, and the median follow‐up time for this cohort was 61.3 months (interquartile range [IQR], 39.0–76.6 months), while it was 60.5 months for the other cohort (IQR, 44.9–80.3 months). Disease recurrence was experienced by 34.7% (61/176) of the patients. Compared to the non‐LNG‐IUS group, the LNG‐IUS group had a lower recurrence rate 1 year after COS (5.4% (2/37) versus 20.9% (29/139), p = .034). The use of LNG‐IUS was associated with a reduced recurrence rate 1 year after COS (hazard ratio = 0.203, 95% confidence interval [0.042–0.984], p = .048). The overall clinical pregnancy rate reached as high as 65.3% (115/176), while the cumulative live birth rates were up to 46.6% (85/176). We found that LNG‐IUS during COS did not impact oocyte yield, ET, or pregnancy outcomes. The placement of LNG‐IUS during COS in EEC/EAH patients is worth considering, as it is likely to reduce the recurrence of endometrial lesions without affecting fertility outcomes.

Hypoxia‐mediated high expression of TRIM15 promotes malignant progression of high‐grade serous ovarian cancer through activation of AKT signaling pathway by K63 ubiquitination

AbstractThe tripartite motif (TRIM) family member TRIM15 is an E3 ubiquitin ligase that is abnormally expressed in a variety of tumors, but its role and mechanism in high‐grade serous ovarian cancer (HGSOC) are unclear. Here, we found for the first time that TRIM15 was upregulated in HGSOC and was associated with poor overall survival. Functional experiments showed that TRIM15 drove the proliferation of HGSOC cells and inhibited the apoptosis of tumor cells in vivo and in vitro. In terms of mechanism, we found that TRIM15 contributed to the malignant proliferation of HGSOC cells by promoting the activation of AKT and that there was a direct binding between them. TRIM15 induced lysine‐63 (K63) ubiquitination of AKT through its Ring domain, which in turn activated the AKT signaling pathway. In addition, TRIM15‐mediated K63 ubiquitination occurs mainly in the pleckstrin homology (PH) domain of AKT. We further identified other proteins and their functions regulated by TRIM15 in HGSOC cells by ubiquitin proteomic analysis. Furthermore, hypoxia‐inducible factor‐1α promoted TRIM15 transcriptional activation by binding to the hypoxia response elements of the TRIM15 promoter. Our study suggests that TRIM15 induces K63 ubiquitination of the AKT PH domain through its Ring domain and activates the AKT signaling pathway, thereby promoting HGSOC progression. In addition, the abnormally high expression of TRIM15 was associated with the hypoxic microenvironment of HGSOC tissues.

Sex and organ‐specific risk and temporal trends of human papillomavirus‐associated anogenital cancer among solid organ transplant recipients in the United States

Abstract Solid organ transplant recipients (SOTRs) have an elevated risk of persistent infection of human papillomavirus (HPV) and associated anogenital (cervical, vulva, and vaginal among women, penile among men and anal among both men and women) cancers. Risk stratification and temporal trends of cancer incidence will help early detection, evaluation, management, and treatment of post‐transplant cancers over time. We analyzed data of 239,613 heart, lung, liver, and kidney transplant recipients registered from 1987 to 2020 in the U.S. Scientific Registry of Transplant Recipients (SRTR) with cancer diagnosis reported during follow‐up. There were 693 new cases of HPV‐associated anogenital cancers, including 176 anal, 118 cervical, 310 vulvar, and 89 penile cancers. The age‐adjusted incidence rates and confidence intervals (IRs [95% CI] per 100,000 person‐years) were anal (10.5 [9.1, 12.2]), cervical (17 [14.2, 20.4]), vulvar (44.2 [39.5, 49.4]), and penile (9.0 [7.3, 11.1]). Overall, the risk of all cancers among SOTRs remains elevated compared with the U.S. general population: standardized incidence ratio (SIR) for anal (2.73 [2.34, 3.14]), cervical (1.46 [1.21, 1.73]), vulvar (8.82 [7.87, 9.83]), and penile (6.13 [3.38, 9.70]). Lung recipients showed the highest IR for anal, vulvar, and penile cancer, while heart recipients demonstrated the highest IR for cervical cancer. Similarly, the 10‐year cumulative incidence (per 100,000 persons) of anal (124), vulvar (523) and penile (95) cancer was highest among lung recipients, while the highest cumulative incidence of cervical cancer (231) was among heart recipients. These data can help develop risk stratification for HPV‐associated cancer screening and management among SOTRs.

Beta‐blockers and epithelial ovarian cancer survival: A Norwegian population‐based cohort study

AbstractCancer diagnosis and therapy cause stress to the body. Preclinical studies have shown that stress hormones can stimulate tumor progression and metastasis by interacting with β‐adrenergic receptors, and that β‐blockers can inhibit those processes. We assessed if β‐blocker use was associated with survival in a nationwide cohort of women with epithelial ovarian cancer (EOC). We identified all women aged ≥40 years who underwent EOC surgery in 2004–2018 in Norway through the Cancer Registry of Norway. We estimated the association between peri‐diagnostic and post‐diagnostic β‐blocker use and survival. We used Cox models, adjusted for sociodemographic and health factors, and reported hazard ratios (HRs) and 95% confidence intervals (CIs). The difference in overall survival time between β‐blocker users and non‐users was estimated as the difference in restricted mean survival time at 5 years after diagnosis using flexible parametric models. We included 3911 women with EOC; 540 (14%) used β‐blockers at diagnosis, 1672 (43%) died of the disease, and 1882 (48%) died overall. We found an association between peri‐diagnostic β‐blocker use and longer EOC‐specific survival (HR = 0.85, 95%CI 0.73–1.00; p‐value = 0.048), and an indication of an association with overall survival (HR = 0.89, 95%CI 0.77–1.02; p‐value = 0.101). Analysis of post‐diagnostic β‐blocker use, which included only women who survived 12 months or longer (n = 3344), found similar associations. At 5 years from diagnosis, peri‐diagnostic β‐blocker users lived on average 1.28 months longer than non‐users (95%CI 0.01–2.60 months). The results support the hypothesis that β‐blocker use improves EOC‐specific survival in women with EOC.

Genetic variants of FER and SULF1 in the fibroblast‐related genes are associated with non–small‐cell lung cancer survival

AbstractFibroblasts are important components in the tumor microenvironment and can affect tumor progression and metastasis. However, the roles of genetic variants of the fibroblast‐related genes (FRGs) in the prognosis of non–small‐cell lung cancer (NSCLC) patients have not been reported. Therefore, we investigated the associations between 26,544 single nucleotide polymorphisms (SNPs) in 291 FRGs and survival of NSCLC patients from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. In Cox regression multivariable analysis, we found that 661 SNPs were associated with NSCLC overall survival (OS). Then we validated these SNPs in another independent replication dataset of 984 patients from the Harvard Lung Cancer Susceptibility (HLCS) Study. Finally, we identified two independent SNPs (i.e., FER rs7716388 A>G and SULF1 rs11785839 G>C) that remained significantly associated with NSCLC survival with hazards ratios (HRs) of 0.87 (95% confidence interval [CI] = 0.77–0.98, p = 0.018) and 0.88 (95% CI = 0.79–0.99, p = 0.033), respectively. Combined analysis for these two SNPs showed that the number of protective alleles was associated with better OS and disease‐specific survival. Expression quantitative trait loci analysis indicated that the FER rs7716388 G allele was associated with the up‐regulation of FER mRNA expression levels in lung tissue. Our results indicated that these two functional SNPs in the FRGs may be prognostic biomarkers for the prognosis of NSCLC patients, and the possible mechanism may be through modulating the expression of their corresponding genes.

Incidence, characteristics and outcome of therapy‐related myeloid neoplasms in women with epithelial ovarian cancer after exposure to poly‐ADPribose polymerase inhibitors: A cancer center experience

AbstractPoly(ADP‐ribose) polymerase inhibitors (PARPi) target the DNA repair pathways and have been established in epithelial ovarian cancer (EOC) as maintenance therapy inducing prolonged survival. However, recently published data showed that PARPi may increase the risk of therapy‐related myeloid neoplasms (t‐MN) including myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Herein, we investigated the incidence, characteristics, and management of t‐MN among EOC patients after exposure to PARPi in a Greek Cancer Center. We analyzed 112 consecutive EOC patients treated with PARPi with a median age of 58 years (range 28–84). Olaparib and Niraparib were used in 90 and 22 patients, respectively. The median number of previous chemotherapy lines and duration of treatment with PARPi were 2 (range 1–9) lines and 12 (range 2–24) months, respectively. The incidence of t‐MN among patients treated with PARPi was 3.57% (4/112). Patients with t‐MN were distributed as follows: t‐MDS: 1, t‐MDS/AML: 1, t‐AML: 2. We observed adverse cytogenetic features in t‐MN patients leading to dismal prognosis. In conclusion, in accordance with previous real‐world reports, we confirm a notable risk for t‐MN in EOC patients treated with PARPi. As PARPi are an emerging therapy for many neoplasms, there is an unmet clinical need to identify patients who are considered at high risk for developing t‐MN post‐therapy with PARPi in order to introduce potential preventive strategies.

Choline kinases: Enzymatic activity, involvement in cancer and other diseases, inhibitors

AbstractOne of the aspects of tumor metabolism that distinguish it from healthy tissue is the phosphorylation of choline by choline kinases, which initiates the synthesis of phosphatidylcholine. Presently, there is a lack of comprehensive reviews discussing the current understanding of the role of choline kinase in cancer processes, as well as studies on the anti‐tumor properties of choline kinase inhibitors. To address these gaps, this review delves into the enzymatic and non‐enzymatic properties of CHKα and CHKβ and explores their precise involvement in cancer processes, particularly cancer cell proliferation. Additionally, we discuss clinical aspects of choline kinases in various tumor types, including pancreatic ductal adenocarcinoma, ovarian cancer, lung adenocarcinoma, lymphoma, leukemia, hepatocellular carcinoma, colon adenocarcinoma, and breast cancer. We examine the potential of CHKα inhibitors as anti‐tumor drugs, although they are not yet in the clinical trial phase. Finally, the paper also touches upon the significance of choline kinases in non‐cancerous diseases.

Development and validation of a lung cancer polygenic risk score incorporating susceptibility variants for risk factors

AbstractIncorporating susceptibility genetic variants of risk factors has been reported to enhance the risk prediction of polygenic risk score (PRS). However, it remains unclear whether this approach is effective for lung cancer. Hence, we aimed to construct a meta polygenic risk score (metaPRS) of lung cancer and assess its prediction of lung cancer risk and implication for risk stratification. Here, a total of 2180 genetic variants were used to develop nine PRSs for lung cancer, three PRSs for different histopathologic subtypes, and 17 PRSs for lung cancer‐related risk factors, respectively. These PRSs were then integrated into a metaPRS for lung cancer using the elastic‐net Cox regression model in the UK Biobank (N = 442,508). Furthermore, the predictive effects of the metaPRS were assessed in the prostate, lung, colorectal, and ovarian (PLCO) cancer screening trial (N = 108,665). The metaPRS was associated with lung cancer risk with a hazard ratio of 1.33 (95% confidence interval: 1.27–1.39) per standard deviation increased. The metaPRS showed the highest C‐index (0.580) compared with the previous nine PRSs (C‐index: 0.513–0.564) in PLCO. Besides, smokers in the intermediate risk group predicted by the clinical risk model (1.34%–1.51%) with the intermediate‐high genetic risk had a 6‐year average absolute lung cancer risk that exceeded the clinical risk model threshold (≥1.51%). The addition of metaPRS to the clinical risk model showed continuous net reclassification improvement (continuous NRI = 6.50%) in PLCO. These findings suggest the metaPRS can improve the predictive efficiency of lung cancer compared with the previous PRSs and refine risk stratification for lung cancer.

Use of menopausal hormone therapy before and after diagnosis and ovarian cancer survival—A prospective cohort study in Australia

AbstractMenopausal hormone therapy (MHT) use before ovarian cancer diagnosis has been associated with improved survival but whether the association varies by type and duration of use is inconclusive; data on MHT use after treatment, particularly the effect on health‐related quality of life (HRQOL), are scarce. We investigated survival in women with ovarian cancer according to MHT use before and after diagnosis, and post‐treatment MHT use and its association with HRQOL in a prospective nationwide cohort in Australia. We used Cox proportional hazards regression to estimate hazard ratios (HR) and 95% confidence intervals (CI) and propensity scores to reduce confounding by indication. Among 690 women who were peri‐/postmenopausal at diagnosis, pre‐diagnosis MHT use was associated with a significant 26% improvement in ovarian cancer‐specific survival; with a slightly stronger association for high‐grade serous carcinoma (HGSC, HR = 0.69, 95%CI 0.54–0.87). The associations did not differ by recency or duration of use. Among women with HGSC who were pre‐/perimenopausal or aged ≤55 years at diagnosis (n = 259), MHT use after treatment was not associated with a difference in survival (HR = 1.04, 95%CI 0.48–2.22). Compared to non‐users, women who started MHT after treatment reported poorer overall HRQOL before starting MHT and this difference was still seen 1–3 months after starting MHT. In conclusion, pre‐diagnosis MHT use was associated with improved survival, particularly in HGSC. Among women ≤55 years, use of MHT following treatment was not associated with poorer survival for HGSC. Further large‐scale studies are needed to understand menopause‐specific HRQOL issues in ovarian cancer.

Long‐term human papillomavirus genotype‐specific risk of cervical high‐grade intraepithelial lesion and cancer—By age group and triage cytology

Abstract Human papillomavirus (HPV) genotypes possess different cervical high‐grade intraepithelial lesion and cancer (CIN2+) risks. HPV genotyping is a promising method to increase the specificity of primary HPV screening, but the optimal management of the infections with different genotypes has not been established. We aimed to assess long‐term HPV genotype‐specific CIN2+ risks, stratified by age and triage cytology result in a population‐based cervical cancer screening program. This is a prospective study of 5253 HPV‐positive individuals from the Finnish randomized HPV screening trial, with up to 18 years of follow‐up. HPV‐positive samples were genotyped using Luminex and BD Onclarity assays. The genotyping data were linked to data from four different nationwide health registries. The primary outcome was HPV genotype‐specific cumulative incidence of CIN2+. The CIN2+ cumulative incidence was the highest for HPV16 (38.1%), followed by HPV33/58 (25.4%) and HPV31 (22.2%). The lowest incidences were observed for HPV56/59/66 (4.4%), HPV35/39/68 (6.5%), and HPV51 (7.5%). Individuals aged 50 or older at the entry test had lower cumulative incidences for the highest‐risk genotypes. The cytology stratification showed that for the infections with the highest risks, normal cytology triage did not guarantee a low CIN2+ risk. On the other hand, HPV51 and HPV56/59/66 had a low risk even with an abnormal cytology result. The findings suggest that individuals with HPV16, HPV33/58, and HPV31 infections could be referred immediately to colposcopy. Sending individuals with low‐risk genotypes, HPV35/39/68, HPV51, or HPV56/59/66 infections with normal cytology back to routine screening could increase screening specificity.

Association between coffee and tea consumption and ovarian cancer incidence: A prospective analysis in the PLCO dataset

AbstractEpidemiological evidence regarding the relationship between coffee and tea consumption and the risk of ovarian cancer (OC) is inconsistent. Therefore, we aimed to quantitatively investigate this topic in a large prospective cohort study. This cohort study included 24,715 individuals recruited from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trials between 1993 and 2001. The data used for our analysis included the latest follow‐up information collected up to 2015. Coffee intake of ≥4 cups/day (hazard ratio [HR], 0.586; 95% confidence interval [CI]: 0.356–0.966) or caffeine intake of 458.787 mg/day (HR, 0.607; 95% CI: 0.411–0.895) were associated with the lowest HR of incident OC in the fully adjusted model. Participants who consumed varying amounts of tea did not exhibit a statistically significant reduction in the risk of OC. Our findings suggest that a higher consumption of coffee or caffeine is associated with a reduced risk of OC. However, no statistically significant association was observed between tea consumption and the risk of OC.

Prediagnostic use of menopausal hormone therapy and long‐term survival of localized epithelial ovarian cancer: The Extreme study

AbstractUse of menopausal hormone therapy (MHT) prior to an epithelial ovarian cancer (EOC) diagnosis has been suggested to be associated with improved survival. In a recent nationwide cohort study, we found that prediagnostic long‐term MHT use, especially estrogen therapy (ET), was associated with improved long‐term survival in women with nonlocalized EOC. Our aim was to investigate the influence of prediagnostic MHT use on long‐term survival among women with localized EOC in the same nationwide study. Our study cohort comprised all women aged 50 years or older with an EOC diagnosis in Denmark 2000–2014 (n = 2097) identified from the Extreme study. We collected information on usage of systemic ET and estrogen plus progestin therapy (EPT) from the Danish National Prescription Registry. By using pseudo‐values, 5‐ and 10‐year absolute and relative survival probabilities were estimated with 95% confidence intervals (CIs) while adjusting for histology, comorbidity, and income. Relative survival probabilities >1 indicate better survival. The 5‐year absolute survival probabilities were 61% and 56%, respectively, among women who were nonusers and users of prediagnostic MHT, whereas these numbers were 46% and 41%, respectively, regarding 10‐year survival. Use of MHT was not significantly associated with an improved 5‐ or 10‐year survival in women with localized EOC (5‐year relative survival probability = 0.95, 95% CI: 0.89–1.02; 10‐year relative survival probability = 0.92, 95% CI: 0.84–1.02). Similar findings were seen for systemic ET or EPT use. Our findings do not suggest a positive benefit from prediagnostic MHT use on long‐term survival of localized EOC.

Causal effects of endometriosis on cancer risk: A Mendelian randomization study

AbstractEndometriosis has been reported in epidemiological studies to be associated with certain types of cancer. However, the presence of reverse causality and residual confounding due to common risk factors introduces uncertainty regarding the extent to which endometriosis itself contributes to the development of cancer. We performed the Mendelian randomization (MR) to investigate the causal associations between endometriosis and 34 different types of cancers. The results of the inverse‐variance‐weighted (IVW) model suggested that genetic predisposition to endometriosis was causally associated with an increased risk for ovarian cancer (OR = 3.2913; p‐value = .0320). The genetic liabilities to endometriosis had causal associations with the decreased risk for skin cancer (OR = 0.9973; p‐value = .0219), hematological cancer (OR = 0.9953; p‐value = .0175) and ER− breast cancer (OR = 0.6960; p‐value = .0381). The causal association of the above combinations were robust by test of heterogeneity and pleiotropy. Together, our study suggests that endometriosis had causal effect on cancer risk.

Comments on “Randomized, two‐arm, non‐comparative phase 2 study of olaparib plus cediranib or durvalumab in HRR‐mutated, platinum‐resistant ovarian cancer: A substudy of KGOG 3045”

Targeting UBR5 inhibits postsurgical breast cancer lung metastases by inducing CDC73 and p53 mediated apoptosis

AbstractUBR5 is a HECT domain E3 ubiquitin ligase that is frequently amplified in breast, ovarian and prostate cancers. Heightened UBR5 expression plays a profound role in tumor growth through immune‐dependent mechanisms; however, its mode of action in driving tumor metastasis has not been definitively delineated. Herein, we used a tetracycline (Tet)‐inducible RNAi‐mediated expression silencing cell system to investigate how UBR5 enables postsurgical mammary tumor metastatic growth in mouse lungs without the continuous influence of the primary lesion. In vitro, Ubr5 knockdown induces morphological and molecular changes characteristic of epithelial‐mesenchymal transition (EMT). In vivo, UBR5 promotes lung metastasis in an E3 ubiquitin ligase‐dependent manner. Moreover, doxycycline‐induced UBR5 expression knockdown in metastatic cells in the lungs, following removing the primary tumors, resulted in increased apoptosis, decreased proliferation and prolonged survival, whereas silencing the expression of cell division cycle 73 (CDC73), a tumor suppressor and E3 ligase substrate of UBR5, reversed these effects. Transcriptome analyses revealed a prominent role of the p53 pathway in dovitinib‐induced apoptosis of tumor cells differentially regulated by UBR5 and CDC73. In human triple‐negative breast cancer (TNBC) patient specimens, a strong inverse correlation was observed between UBR5 and CDC73 protein levels, with reduced CDC73 expression at metastatic sites compared to primary lesions. Furthermore, a xenograft model of human TNBC recapitulated the metastatic properties and characteristics of the unique UBR5‐CDC73 functional antagonism. This study reveals the novel and critical roles and intricate relationships of UBR5, CDC73 and p53 in postsurgical breast cancer metastasis and indicates the potential of targeting this pathway in cancer therapy.

Reply to: Comments on “Randomized, two‐arm, non‐comparative phase 2 study of olaparib plus cediranib or durvalumab in HRR‐mutated, platinum‐resistant ovarian cancer: A substudy of KGOG 3045”

Trps1 predicts poor prognosis in advanced high grade serous ovarian carcinoma

AbstractTRPS1 is aberrantly expressed in a variety of tumors, including breast, prostate, and gastric cancers, and is strongly associated with tumorigenesis or prognosis. However, the role of TRPS1 in high grade serous ovarian carcinoma (HGSC) is unknown. We investigated the relationship between TRPS1 expression and clinicopathology in HGSC patients. The tumor‐related regulatory mechanisms of TRPS1 was explored through in vivo and vitro experiments. The results showed that TRPS1 was highly expressed in HGSC compared to normal tissues. It was also linked to the cell proliferation index Ki67 and poor prognosis. In vivo experiments showed that knockdown of TRPS1 could inhibit tumor growth. In vitro experiments, knockdown of TRPS1 inhibited the proliferation of ovarian cancer cells. TRPS1 exerted its regulatory role as a transcription factor, binding to the PSAT1 promoter and promoting the expression of PSAT1 gene. Meanwhile, PSAT1 was positively correlated with CCND1 expression. These results suggest that TRPS1 affects HGSC proliferation and cell cycle by regulating PSAT1 and thus CCND1 expression.

Multiplexed genome editing by in vivo electroporation of Cas9 ribonucleoproteins effectively induces endometrial carcinoma in mice

AbstractSynergistic effects among multiple gene mutations are involved in cancer development and progression. However, developing genetically modified mouse models to analyze various combinations of mutations is extremely labor‐intensive and time‐consuming. To address these problems, we developed a novel method for in vivo multiplexed genome editing of the murine uterus to model human endometrial carcinoma (EMC). To do this, we injected a CRISPR‐Cas9 ribonucleoprotein complex into the uterine cavity of adult female mice, followed by electroporation. Evaluation of reporter mice demonstrated that genome editing occurred specifically in uterine epithelial cells, which are the origin of EMCs. Simultaneous targeting of Pten/Trp53/Lkb1, or targeting of Pten/Lkb1 along with the Ctnnb1ΔEx3 mutation, resulted in efficient generation of invasive tumors in wild‐type females within 3 months. This novel method will enable rapid and easy validation of many combinations of gene mutations that lead to endometrial carcinogenesis.

Non‐steroidal anti‐inflammatory medication use and endometrial cancer survival: A population‐based Norwegian cohort study

AbstractWhile nonsteroidal anti‐inflammatory drugs (NSAIDs) have been shown to improve survival in certain cancers, data in patients with endometrial cancer (EC) is conflicting. This study investigated use of aspirin and nonaspirin NSAIDs (NA‐NSAIDs) and EC‐specific—and all‐cause death. This nationwide cohort study linked data from the Cancer Registry of Norway with The Norwegian Prescription database. Patients diagnosed with EC from 2004 to 2018 were included. Post‐diagnosis exposure to aspirin and NA‐NSAIDs was defined as ≥3 consecutive prescriptions ≥30 days after EC diagnosis, with pre‐diagnosis use as ≥2 filled prescriptions <6 months prior to diagnosis. Follow‐up started 10 months after diagnosis. Hazard ratios for the risk of death were calculated with multivariable Cox‐regression models. Our study population included 7751 individuals with EC, 685 (9%) were aspirin users and 620 (8%) were NA‐NSAIDs users. The median follow‐up time was 5.0 years, with 1518 (20%) deaths observed (n = 728 (9%) EC‐specific). In multivariable analysis, aspirin use was significantly associated with a 19% higher risk of all‐cause death compared to non‐users (HR = 1.19, 95% CI [1.01–1.41]). The association was stronger among combined pre‐ and postdiagnosis use (HR = 1.35 [1.12–1.64]). NA‐NSAIDs use increased risk of cancer‐related death (HR = 1.25 [0.99–1.58]) and there was a dose–response association with significantly higher risk of cancer‐specific death with higher cumulative doses (HR = 1.33 [1.02–1.75]). We found a higher risk of cancer‐specific—and all‐cause death among patients that used aspirin and NA‐NSAIDs after a diagnosis of EC. Further studies on the biological mechanisms underlying these associations are needed.

Acceptability and somatic mutations in cervicovaginal self‐sampling for early endometrial cancer detection in women with Lynch syndrome

AbstractNew molecular approaches are being developed to detect endometrial cancer using minimally invasive sampling methods. This study aims to evaluate the acceptability of self‐collected cervicovaginal samples among women with Lynch syndrome, a group at high risk for developing endometrial cancer. Participants collected cervicovaginal self‐samples and answered an at‐home acceptability questionnaire in a cross‐sectional study. Self‐samples from a subset of these women were analyzed for somatic mutations using next‐generation sequencing (NGS), targeting a panel of 47 genes. A total of 61 (88.4%) out of 69 eligible women participated in the study. The overall self‐sampling experience was rated good or very good (N = 55, 90.2%). Most of the women were confident about correctly sampling (N = 58, 95.1%), and most reported no or mild pain (N = 56, 91.8%). During self‐sample collection, most women reported feeling calm and comfortable and experiencing safety, privacy, and normality. In a pilot study using a subset of 15 samples, five somatic variants were identified in four self‐samples (4/15, 26.7%) in ACVR2A, ARID1A, APC, and KMT2D. During follow‐up, three out of four women with variants detected in the self‐sample underwent prophylactic hysterectomy at a median of 9.1 months, while one out of four developed endometrial cancer after 3.9 years since the collection of the sample. Self‐sampling is well‐accepted and well‐tolerated in women with Lynch syndrome and could potentially reduce some barriers associated with gynaecological surveillance. Further research is needed to evaluate the feasibility of implementing cervicovaginal self‐collection and the accuracy of molecular testing for gynaecological surveillance in women with Lynch syndrome.

High‐risk human papillomavirus genotypes in previously unscreened reproductive‐age women in Ethiopia: A community‐based cohort study

AbstractHigh‐risk human papillomavirus (hrHPV) genotype is needed for adequate cervical cancer screening and HPV vaccination program evaluation as recommended by different guidelines. We aimed to assess the rate of HPV infection and HPV genotype distribution using vaginal self‐sampling in a cohort of unscreened reproductive‐age women in Ethiopia. A community‐based cohort study was conducted with women aged 23–46 living in Adama, Ethiopia. A total of 885 self‐collected vaginal swabs were obtained and tested for hrHPV genotypes with the real‐time polymerase chain reaction technique. The overall hrHPV prevalence was 21.1% (187/885, 95% confidence interval [CI]: 18.5–24.0). Among women living with human immunodeficiency virus, 46% (30/56) (95% CI: 33.7–59) were hrHPV positive compared with 19% (157/820) (95% CI: 16.2–22) of human immunodeficiency virus‐negative women. The most frequent genotypes were HPV16 (3.1%), HPV51 (3.1%), HPV35 (2.6%), HPV56 (2.6%), HPV52 (2.4%), HPV31 (2.5%), and HPV39 (2.5%). Among the 187 HPV‐positive women in self‐samples, HPV 16/18 was found in 21% (39), HPV 16/18/45 was found in 24% (44), and HPV 16/18/31/33/45/52/58 was prevalent in 56% (104). Out of 116 biopsies, 7% (8) had cervical intraepithelial lesions and worse identified. Of these eight cervical intraepithelial lesions and worse patients, only 25% tested positive for HPV‐16; none tested positive for HPV‐18 or 45. One out of five women tested positive for hrHPV genotypes. Other HPV genotypes not covered by the quadrivalent HPV vaccine but associated with clinically significant cervical high‐grade lesions or cancer were detected in 75%. It is more effective to prevent cervical cancer by switching to the nine‐valent HPV vaccine.

One‐stop molecular classification of endometrial carcinoma using comprehensive next‐generation sequencing

AbstractThis study aims to investigate the feasibility of molecular classification using only comprehensive next‐generation sequencing‐based techniques and its relationship with survival outcomes in patients with endometrial cancer. Paired tumor‐normal sequencing data of 1021 cancer‐related genes using tumor tissues or peripheral blood samples and clinical data were retrospectively collected from a cohort of endometrial cancers. The microsatellite instability status was inferred using the MSIsensor (v0.5) with a cut‐off of 8%. Sixty patients were classified into four groups: POLEMUT group (13.3%), MSI‐H group (20%), TP53WT group (45%) and TP53MUT group (21.7%). Patients within TP53MUT group were more common in serous carcinoma compared to endometrioid carcinoma (P = .0098). TP53WT was significantly correlated with early stage and low grade. TP53MUT group was associated with significantly worse DFS compared to MSI‐H group and TP53WT group (P = .014 and .004, respectively). Comprehensive next‐generation sequencing is a reliable and simple method to stratify the prognosis of endometrial carcinoma. It can be potentially used to guide treatment of patients with endometrial cancer in routine practice.

A serum lipidomics study for the identification of specific biomarkers for endometrial polyps to distinguish them from endometrial cancer or hyperplasia

AbstractEndometrial diseases, including endometrial polyps (EP), endometrial cancer (EC) and endometrial hyperplasia (EH), are common gynecological diseases that affect women of childbearing and perimenopausal age. Clinically, biopsy or imaging methods are usually used to screen and diagnose these diseases; however, due to the invasiveness and heterogeneity of these tests, a noninvasive, convenient, objective and accurate biomarker is needed for the differential diagnosis of EP, EC or EH. In the present study, serum samples from 326 patients with endometrial diseases and 225 healthy volunteers were analyzed using nontargeted lipidomics. A combination of multivariate and univariate analyses was used to identify and qualify six, eight and seven potential biomarkers in the sera from patients with EP, EC and EH, respectively. Using a logistic regression algorithm and receiver operating characteristic (ROC) curve analysis, a biomarker panel including four specific EP biomarkers, 6‐keto‐PGF1α, PA(37:4), LysoPC(20:1) and PS(36:0), showed good classification and diagnostic ability in distinguishing EP from EC or EH. The biomarker panel for distinguishing EP from EC yielded an area under the curve (AUC) of 0.915, sensitivity of 100% and specificity of 72.41%, while that for distinguishing EP from EH yielded an AUC of 1.000, sensitivity of 100% and specificity of 100%. The two diagnostic models also showed good diagnostic abilities in the validation set. Therefore, this biomarker panel can be used as a rapid diagnostic method to assist in imaging examinations and provide a reference for clinicians in the identification and diagnosis of endometrial diseases.

Endometrial cancer in Lynch syndrome

AbstractLynch syndrome (LS) is an autosomal dominant inherited disease caused by germline pathogenic variants (PVs) in mismatch repair (MMR) genes. LS‐associated endometrial cancer (LS‐EC) is the most common extraintestinal sentinel cancer caused by germline PVs in MMR genes, including MLH1, MSH2, MSH6 and PMS2. The clinicopathologic features of LS‐EC include early age of onset, lower body mass index (BMI), endometrioid carcinoma and lower uterine segment involvement. There has been significant progress in screening, diagnosis, surveillance, prevention and treatment of LS‐EC. Many studies support universal screening for LS among patients with EC. Screening mainly involves a combination of traditional clinical criteria and molecular techniques, including MMR‐immunohistochemistry (MMR‐IHC), microsatellite instability (MSI) testing, MLH1 promoter methylation testing and gene sequencing. The effectiveness of endometrial biopsy and transvaginal ultrasound (TVS) for clinical monitoring of asymptomatic women with LS are uncertain yet. Preventive strategies include hysterectomy and bilateral salpingo‐oophorectomy (BSO) as well as chemoprophylaxis using exogenous progestin or aspirin. Recent research has revealed the benefits of immunotherapy for LS‐EC. The NCCN guidelines recommend pembrolizumab and nivolumab for treating patients with advanced or recurrent microsatellite instability‐high (MSI‐H)/mismatch repair‐deficient (dMMR) EC.

Dysbiosis of the endometrial microbiota and its association with inflammatory cytokines in endometrial cancer

AbstractThe underlying molecular mechanisms involved in the pathogenesis of endometrial cancer (EC) are still not well understood. Our goal was to investigate the composition of the endometrial microbiota and the association with inflammatory cytokines in EC. Endometrial microbiota profiles of women with EC (n = 25) and benign uterine lesions (BUL, n = 25) were assessed by 16S ribosomal RNA gene amplicon sequencing. The expression levels of interleukin‐6 (IL‐6), interleukin‐8 (IL‐8), and interleukin‐17 (IL‐17) mRNA and protein in the endometrial tissues of the two groups were determined by real‐time quantitative polymerase chain reaction and Western blot, respectively. There were significant differences in alpha diversity based on the observed operational taxonomic units (P = .002), Pielou evenness (P = .001), and Shannon index (P < .001) between EC and BUL groups. Significant differences were also found in Bray‐Curtis (P = .001) and unweighted UniFrac (P = .001) beta diversity measures between the two groups. At the genus level, Micrococcus was more abundant in the EC group. Pseudoramibacter_Eubacterium, Rhodobacter, Vogesella, Bilophila, Rheinheimera, and Megamonas were enriched in the BUL group. There were no differences in IL‐8 and IL‐17 protein levels between the two groups, except IL‐6 protein levels. However, the mRNA expression levels of IL‐6, IL‐8, and IL‐17 were significantly different. Moreover, the relative abundances of Micrococcus was positively correlated with IL‐6, and IL‐17 mRNA levels. In conclusion, our results suggested that dysbiosis of endometrial microbiota and the inflammatory cytokines were associated with Micrococcus in EC patients, which might be useful for exploration of the mechanism between the endometrial microbiota and inflammatory responses in future studies.

Mendelian randomization analyses suggest a role for cholesterol in the development of endometrial cancer

AbstractBlood lipids have been associated with the development of a range of cancers, including breast, lung and colorectal cancer. For endometrial cancer, observational studies have reported inconsistent associations between blood lipids and cancer risk. To reduce biases from unmeasured confounding, we performed a bidirectional, two‐sample Mendelian randomization analysis to investigate the relationship between levels of three blood lipids (low‐density lipoprotein [LDL] and high‐density lipoprotein [HDL] cholesterol, and triglycerides) and endometrial cancer risk. Genetic variants associated with each of these blood lipid levels (P < 5 × 10−8) were identified as instrumental variables, and assessed using genome‐wide association study data from the Endometrial Cancer Association Consortium (12 906 cases and 108 979 controls) and the Global Lipids Genetic Consortium (n = 188 578). Mendelian randomization analyses found genetically raised LDL cholesterol levels to be associated with lower risks of endometrial cancer of all histologies combined, and of endometrioid and non‐endometrioid subtypes. Conversely, higher genetically predicted HDL cholesterol levels were associated with increased risk of non‐endometrioid endometrial cancer. After accounting for the potential confounding role of obesity (as measured by genetic variants associated with body mass index), the association between genetically predicted increased LDL cholesterol levels and lower endometrial cancer risk remained significant, especially for non‐endometrioid endometrial cancer. There was no evidence to support a role for triglycerides in endometrial cancer development. Our study supports a role for LDL and HDL cholesterol in the development of non‐endometrioid endometrial cancer. Further studies are required to understand the mechanisms underlying these findings.

Controlled trial of cervical cancer screening frequency among human‐papillomavirus‐vaccinated women

Abstract Cervical screening frequency has not been studied in vaccinees. As the major risk factor, oncogenic human papillomavirus (HPV) is declining due to vaccination. We report a trial to assess the effectiveness of cervical screening frequency among women HPV‐vaccinated as early adolescents (NCT02149030). In 2013, 5626 1992‐1995‐born women, who had received three doses of the HPV16/18 vaccine at ages 12–15 between 2007 and 2010 in a community‐randomized vaccination trial (NCT00534638), were allocated at age 22 into high‐intensity cytology‐based cervical screening by even birth date (Arm A1) or into low‐intensity cytology‐based cervical screening by odd birth date (Arm A2). One thousand three hundred thirty‐three women who received HPV16/18 vaccination at age 18 attended a safety of low intensity‐screening arm (Arm A3). Low‐intensity screening, where low‐grade cytological abnormalities were not revealed for 6 years, was compared to the standard high‐intensity screening used in Finland at the time. The prevalence of cytological and HPV findings was calculated at ages 22/25/28. The hazard ratio of histopathologically confirmed immediate cervical cancer precursors (HSIL/CIN2+) among participants was compared between low‐ and high‐intensity screening arms. The overall occurrence of CIN2+ was comparable in Arms A1, 0.70% and A2, 0.66%, with the corresponding hazard ratio at age 28 being 0.97 (95% confidence intervals, 0.50–1.88). By age 28, the occurrence of vaccine‐HPV types 16/18 was reduced up to 88% in the 12‐to‐15 compared to 18‐year‐old HPV‐vaccinated women. In conclusion, the risk of CIN2+ was similar for HPV‐vaccinated women who attended low‐intensity cervical screening compared to high‐intensity screening most likely due to the decline of oncogenic HPVs.

Evaluating polygenic risk scores in assessing risk of nine solid and hematologic cancers in European descendants

AbstractGenome‐wide association studies (GWAS) have identified many genetic risk variants for cancers. The utility of these variants in assessing risk of esophageal, gastric and endometrial cancers, as well as melanoma, glioma, diffuse large B‐cell lymphoma, follicular lymphoma, chronic lymphoid leukemia and multiple myeloma, has not been adequately investigated. We constructed a site‐specific polygenic risk score (PRS) for each of these nine cancers using their GWAS‐identified risk variants. Using data from 400 807 participants of European descent in the UK Biobank, a population‐based cohort study, we estimated the hazard ratios of each cancer associated with its PRS using Cox proportional hazard models. During a median follow‐up of 5.8 years, 3905 incident cases of these nine cancers were identified in the cohort. The area under the receiver operating characteristic curve ranged from 0.53 to 0.69 for these cancers. Except for esophageal cancer, significant dose‐response associations were observed between PRS and cancer risk. Compared to individuals in the middle quintile (40%‐60%) at an average risk, those among the highest 5% of the PRS had a twofold elevated risk of melanoma, glioma, follicular lymphoma or multiple myeloma, and a fourfold elevated risk of chronic lymphoid leukemia. Using PRS, 63.0% of the participants could be classified as having an over twofold elevated risk for at least one cancer. The PRS derived using risk variants identified to date by GWAS showed the potential in identifying individuals at a significantly elevated risk of cancer for prevention.

ABCC4/MRP4 contributes to the aggressiveness of Myc‐associated epithelial ovarian cancer

AbstractEpithelial ovarian cancer (EOC) is a complex disease comprising discrete histological and molecular subtypes, for which survival rates remain unacceptably low. Tailored approaches for this deadly heterogeneous disease are urgently needed. Efflux pumps belonging to the ATP‐binding cassette (ABC) family of transporters are known for roles in both drug resistance and cancer biology and are also highly targetable. Here we have investigated the association of ABCC4/MRP4 expression to clinical outcome and its biological function in endometrioid and serous tumors, common histological subtypes of EOC. We found high expression of ABCC4/MRP4, previously shown to be directly regulated by c‐Myc/N‐Myc, was associated with poor prognosis in endometrioid EOC (P = .001) as well as in a subset of serous EOC with a “high‐MYCN” profile (C5/proliferative; P = .019). Transient siRNA‐mediated suppression of MRP4 in EOC cells led to reduced growth, migration and invasion, with the effects being most pronounced in endometrioid and C5‐like serous cells compared to non‐C5 serous EOC cells. Sustained knockdown of MRP4 also sensitized endometrioid cells to MRP4 substrate drugs. Furthermore, suppression of MRP4 decreased the growth of patient‐derived EOC cells in vivo. Together, our findings provide the first evidence that MRP4 plays an important role in the biology of Myc‐associated ovarian tumors and highlight this transporter as a potential therapeutic target for EOC.

Dual‐specificity phosphatase 6 plays a critical role in the maintenance of a cancer stem‐like cell phenotype in human endometrial cancer

The prognosis of patients with high‐grade or advanced‐stage endometrial cancer remains poor. As cancer stem‐like cells (CSCs) are thought to be associated with endometrial cancers, it is essential to investigate the molecular mechanisms that regulate endometrial CSCs. Dual‐specificity phosphatase 6 (DUSP6) functions as a negative‐feedback regulator of MAPK–ERK1/2 signaling, but its role in endometrial cancer remains unknown. We investigated whether DUSP6 is involved in cancer cell stemness using endometrial cancer cell lines and specimens from endometrial cancer patients. DUSP6 induced the expression of CSC‐related genes including ALDH1, Nanog, SOX2 and Oct4A, increased the population of cells in the G0/G1 phase, and promoted sphere formation ability. DUSP6 knockdown resulted in reduced cell invasion and metastasis, whereas DUSP6 overexpression inhibited apoptosis under serum‐free conditions. Moreover, DUSP6 decreased phosphorylated ERK1/2 and increased phosphorylated Akt levels, which potentially induces CSC features. In patients with endometrial cancers, DUSP6 expression was determined using immunohistochemistry, and based on the results, the patients were dichotomized into high‐ and low‐DUSP6‐expression groups. Progression‐free survival and overall survival were significantly shorter in the high‐DUSP6‐expression group. These results suggest that DUSP6 has potential value as a biomarker of CSCs and as a target of therapies designed to eliminate CSCs in endometrial cancer.

Cumulative exposure to premenopausal obesity and risk of postmenopausal cancer: A population‐based study in Icelandic women

Obesity, often assessed at one point in time, is an established risk factor of several types of cancer, however, associations with cumulative exposure to obesity across the life course are not well understood. We investigated the relationship between combined measures of duration and intensity of premenopausal overweight and obesity and the incidence of postmenopausal breast, endometrial, and colorectal cancers in Icelandic women. Body mass index (BMI) trajectories between ages 20 and 50 of 88,809 women from the Cancer Detection Clinic Cohort were predicted using growth curve models. Indicators of overweight and obesity duration and intensity were computed and their association with risk of postmenopausal breast, endometrial, and colorectal cancers was examined using multivariate Cox models for subjects followed‐up beyond the age of 50 (n = 67,488). During a mean follow‐up of 17 years, incident events of 3,016 postmenopausal breast, 410 endometrial and 987 colorectal cancers were ascertained. Each 0.1 kg/m2 per year increase in BMI between ages 20 and 50 was positively associated with risks of postmenopausal breast, endometrium and colorectal cancers with hazard ratios equal to 1.09 (95% Confidence Interval (CI):1.04–1.13), 1.31 (95% CI: 1.18–1.44) and 1.10 (95% CI: 1.00–1.21), respectively. Compared to women who were never obese, cumulative BMI × years of obesity were linearly positively associated with risk of endometrial cancer, whereas the association with breast cancer was initially positive, but leveled off with increasing cumulative BMI × years. Cumulative exposure to obesity may provide additional insights into the etiology of cancer and should be considered in future studies that assess obesity–cancer relationships.

Phase II, 2‐stage, 2‐arm, PIK3CA mutation stratified trial of MK‐2206 in recurrent endometrial cancer

Endometrial cancers have high rates of phosphoinositide 3‐kinase (PI3K) pathway alterations. MK‐2206 is an allosteric inhibitor of AKT, an effector kinase of PI3K signals. We hypothesized patients with tumors harboring PIK3CA mutations would be more likely to benefit from MK‐2206 than those without PIK3CA mutation. A Phase II study was performed in patients with recurrent endometrial cancer; all histologies except carcinosarcoma were eligible. Up to two prior chemotherapy lines were permitted, excluding prior treatment with PI3K pathway inhibitors. The first 18 patients were treated with MK‐2206 200 mg weekly. Due to unacceptable toxicity, dose was reduced to 135 mg. Co‐primary endpoints were objective response rate (ORR) and progression‐free survival at 6 months (6moPFS). Thirty‐seven patients were enrolled (one ineligible). By somatic PIK3CA mutation analysis, nine patients were mutant (MT) [one with partial response (PR)/6moPFS, two with 6moPFS]. Twenty‐seven patients were wild‐type (WT) (one PR and four 6moPFS). Most common toxicities were rash (44%), fatigue (41%), nausea (42%) and hyperglycemia (31%). Grade 3 and 4 toxicities occurred in 25 and 17% of patients, respectively. Exploratory analysis found serous histology had greater 6moPFS as compared to all other histologies (5/8 vs. 2/28, p = 0.003). PTEN expression was associated with median time to progression (p = 0.04). No other significant associations with PI3K pathway alterations were identified. There is limited single agent activity of MK‐2206 in PIK3CA MT and PIK3CA WT endometrial cancer populations. Activity was detected in patients with serous histology and due to their poor outcomes warrants further study (NCT01307631).

Mutational analysis of cervical cytology improves diagnosis of endometrial cancer: A prospective multicentre cohort study

Endometrial carcinoma (EC) is traditionally diagnosed by a histopathological assessment of an endometrial biopsy, leaving up to 30% of patients undiagnosed due to technical failure or an inadequate amount of tissue. The aim of the current study is to assess whether mutational analysis of cervical cytology or pipelle endometrial biopsies improves the diagnostic accuracy of traditional histopathological diagnosis of EC. This prospective multicentre cohort study included patients surgically treated for EC or a benign gynaecological condition (control group). A Pap brush sample, cervicovaginal self‐sample, pipelle endometrial biopsy and surgical specimen of either the EC or normal endometrium were obtained. A targeted next‐generation sequencing panel was used to analyse these samples for mutations in eight genes. Sensitivity, specificity and predictive values were calculated. Fifty‐nine EC patients and 31 control patients were included. In these patients, traditional histopathological diagnosis by pipelle had a sensitivity of 79% and a specificity of 100%. For EC patients, 97% of surgical specimens contained at least one mutation. Mutational analysis of Pap brush samples, self‐samples and pipelle endometrial biopsies yielded a sensitivity of 78, 67 and 96% with a specificity of 97, 97 and 94%, respectively. Combining one of these three methods with histopathological pipelle endometrial biopsy evaluations yielded a sensitivity of 96, 93 and 96%, respectively. Our study has shown that mutational analysis of either cervical cytology or pipelle endometrial biopsies improves diagnosis of EC. Prospective validation will support implementation in clinical practice.

Associations of pregnancy‐related factors and birth characteristics with risk of endometrial cancer: A Nordic population‐based case–control study

Many pregnancy‐related factors are associated with reduced endometrial cancer risk. However, it remains unclear whether pregnancy‐related complications (e.g., hypertensive conditions) are associated with risk and whether these associations vary by endometrial cancer subtype. Thus, we evaluated the risk of endometrial cancer, overall and by subtype, in relation to pregnancy‐related factors, pregnancy complications and birth characteristics. Utilizing population‐based register data from four Nordic countries, we conducted a nested case–control analysis of endometrial cancer risk. We included 10,924 endometrial cancer cases and up to 10 matched controls per case. Odds ratios (ORs) with 95% confidence intervals (CIs) were derived from unconditional logistic regression models. We further evaluated associations by individual histology (i.e., endometrioid, serous, etc.) or, for rare exposures (e.g., pregnancy complications), by dualistic type (Type I [n = 10,343] and Type II [n = 581]). Preexisting and pregnancy‐related hypertensive conditions were associated with increased endometrial cancer risk (OR [95% CI]: preexisting hypertension 1.88 [1.39–2.55]; gestational hypertension 1.47 [1.33–1.63]; preeclampsia 1.43 [1.30–1.58]), with consistent associations across dualistic type. Increasing number of pregnancies (≥4 vs. 1 birth: 0.64 [0.59–0.69]) and shorter time since last birth (<10 vs. ≥30 years: 0.34 [0.29–0.40]) were associated with reduced endometrial cancer risk, with consistent associations across most subtypes. Our findings support the role for both hormonal exposures and cell clearance as well as immunologic/inflammatory etiologies for endometrial cancer. This research supports studying endometrial hyperplasia, a precursor condition of endometrial cancer, in the context of pregnancy‐related exposures, as this may provide insight into the mechanisms by which pregnancy affects subsequent cancer risk.

Prophylactic salpingectomy for the prevention of ovarian cancer: Who should we target?

Ovarian cancer is the most fatal gynecologic malignancy (50% 5‐year survival) due to a typically advanced stage at diagnosis and a high rate of recurrence. Chemoprevention options are limited, and few interventions have been shown to reduce cancer risk or mortality. Emerging data support the model that fallopian tubes are the site of origin for a proportion of high‐grade serous cancers. This implies that a subset of cancers may be prevented by removing the fallopian tubes while leaving the ovaries intact. Accordingly, there has been shift in clinical practice for average risk women; some now recommend removal of both the fallopian tubes only instead of tubal ligation for sterilization or at the time of benign gynecologic surgery. This has been termed opportunistic salpingectomy and represents a means of decreasing the burden of ovarian cancer by preventing cancers that arise in the fallopian tubes. There have been no detailed, prospective reports that have estimated ovarian cancer risk reduction with opportunistic salpingectomy, neither among women at baseline population risk nor among women at a high risk of developing the disease. The situation is complicated for women with a BRCA mutation—bilateral salpingo‐oophorectomy is a proven means of risk reduction and salpingectomy alone is not the standard of care. Based on the existing data, salpingectomy alone should only be reserved for women with a lifetime risk of ovarian cancer of less than 5%.

Fertility treatment and risk of ovarian cancer in a large nationwide cohort of infertile Danish women

AbstractWhether fertility treatment increases the risk of ovarian cancer has been a concern for many decades, but previous research has yielded conflicting findings. We therefore investigated this association within a large population‐based cohort study of infertile women aged 20–45 years and living in Denmark between 1995 and 2017, as identified in the Danish Infertility Cohort (n = 146,110). The study cohort was linked to nationwide registers to obtain information on fertility drug use, cancer diagnoses, covariates, emigration, and vital status was. Hazard ratios (HR) and 95% confidence intervals (CI) with adjustment for potential confounders for ovarian cancer overall and for serous ovarian cancer were estimated using Cox proportional hazard models. During a median 10.3 years of follow‐up, 114 women were diagnosed with ovarian cancer of which 65 had serous ovarian cancer. Our results showed that the rate of serous ovarian cancer (HR 1.92; 95% CI 1.16–3.17) was increased after every use of progesterone but the association was not affected by increased follow‐up time since first use or with increased cumulative dose. We performed a secondary analysis adding less extensive data from 1971 through 1994 from the Danish Infertility Cohort. In this study cohort, 332 women developed ovarian cancer of which 192 had serous ovarian cancer. The overall results were similar, including the association between every use of progesterone and serous ovarian cancer (HR 2.05: 95% CI: 1.31–3.21). In conclusion, the novel finding that use of progesterone is associated with an increased rate of serous ovarian cancer warrants further investigation.

Efficacy and safety of 5‐aminolevulinic acid‐based photodynamic therapy for cervical low‐grade squamous intraepithelial lesions with HPV infections

Abstract To assess the effectiveness and safety of 5‐aminolevulinic acid‐based photodynamic therapy (5‐ALA PDT) for cervical low‐grade squamous intraepithelial lesions (LSIL) patients with high‐risk human papillomavirus (HR‐HPV) infection and to investigate independent factors that influence the efficacy of PDT treatment. A retrospective analysis was conducted on 530 patients with pathologically confirmed LSIL and HR‐HPV infection, treated between March 2017 and January 2024. All patients underwent 5‐ALA PDT at an interval of 7–14 days, for a total of 3 to 6 sessions. Follow‐ups were conducted 3 and 12 months post‐treatment. The efficacy was assessed using HPV genotyping, ThinPrep cytology test (TCT) and colposcopy‐directed biopsy. The HPV remission rate was 52.08% at 3 months' follow‐up and increased to 69.84% at 12‐month follow‐up, surpassing the rate at 3‐month follow‐up ( p  < 0.001). The LSIL regression rate was 75.85% at 3 months' follow‐up and rose to 86.77% at 12‐month follow‐up, exceeding the rate at 3‐months' follow‐up ( p  < 0.001). Multivariate analysis revealed that single HPV infection (OR 2.296 [95%CI 1.550–3.402]) was an independent predictor of HPV remission after 5‐ALA PDT treatment. Single HPV infection (OR 1.690 [95% CI 1.077–2.652]), type III transformation zone (OR 3.094 [95% CI 1.899–5.041]), HPV remission after PDT treatment (OR 4.938 [95% CI 3.099–7.870]) were independent predictors of LSIL participants receiving total lesion regression after PDT treatment. Adverse reactions were all mild. 5‐ALA PDT is an effective and non‐invasive therapy for LSIL patients with HR‐HPV infection. Identifying predictors of treatment success may optimize patient selection, ultimately improving clinical outcomes.

Human papillomavirus infection and vaccination among young females in rural Uganda

Abstract Cervical cancer is the most common cancer in Uganda. In 2015, a national human papillomavirus (HPV) vaccination program was initiated, targeting girls aged 10 years. To provide a pre‐vaccination baseline to monitor HPV vaccine effectiveness, first‐void urine (FVU) samples were collected from females aged 16–21 years in the General Population Cohort (GPC) in South‐East Uganda, between 2019 and 2023. HPV vaccination status was obtained from questionnaires and vaccination cards. FVU samples were tested for 28 HPV types using Allplex HPV28. Among 1009 participants, 28 type prevalence was 33%, and was higher among females reporting sexual intercourse (aPR = 3.7, 95%CI 2.8–4.8) and HIV infection (PR = 1.4, 95%CI 1.1–1.8). HPV16/18 prevalence was 4.8% overall, and lower in 146 vaccinated (1.4%) than 783 unvaccinated (5.6%) females (aPR = 0.4, 95%CI 0.1–1.4). No decrease was observed in other high‐risk (aPR = 1.5, 95%CIs 1.0–2.2) or low‐risk (aPR = 1.4, 95%CIs 1.0–2.1) types which were more prevalent in vaccinated females. Among vaccinated 16–21 year‐olds, 30.8% ( n  = 45) received one, 44.5% ( n  = 65) two, and 14.3% ( n  = 21) three doses. Vaccination status was also obtained from 1121 younger girls aged 10–15 years from the same GPC population, among whom 42.8% ( n  = 480) were vaccinated, 47.1% ( n  = 226) with one, 44.2% ( n  = 212) two, and 6.7% ( n  = 32) three doses. In conclusion, we report high HPV prevalence in young women in Uganda and see first impacts of vaccination on HPV16/18 infection. This population, shown to have suboptimal HPV vaccine coverage and heterogeneity in doses received, can serve as a robust baseline for future evaluations of HPV vaccine effectiveness.

Single visit screen‐triage‐treat strategy using GeneXpert ‐based HPV testing of self‐collected cervicovaginal samples and thermal ablation treatment for cervical cancer prevention among women in Lilongwe, Malawi

Abstract Human papillomavirus (HPV) testing is now recommended for primary screening for invasive cervical cancer (ICC) among women. We evaluated same‐day completion of an HPV screen‐triage‐treat algorithm consisting of: (1) GeneXpert high‐risk HPV testing of self‐collected vaginal samples, (2) visual inspection with acetic acid (VIA) and colposcopy for HPV+ women, and (3) thermal ablation (TA) treatment for HPV+ women with acetowhite cervical lesions eligible for TA by colposcopy, in Lilongwe, Malawi. We calculated same‐day completion rates of the screening algorithm as the proportion of: (a) HPV+ women who had VIA the same day, and (b) HPV+ women with ablation‐eligible lesions by colposcopy who received TA the same day. Between June 2020 and February 2022, we enrolled 1250 participants: 625 women living with HIV (WLWH) and 625 without HIV. Participant median age was 35 years (IQR 30–40). A total of 698 (55.8%) had no prior ICC screening, and 589 (99.7%) of WLWH were on antiretroviral therapy. HPV DNA positivity overall was 38.1% ( n  = 476) and higher among WLWH ( n  = 295, 47.2%) than those without HIV ( n  = 181, 29.0%). Overall, 469 (98.5%) of the 476 HPV+ women had VIA performed. Most HPV+ women had VIA performed the same day (96%, 95% confidence interval [CI]: 94%, 98%). Similarly, most HPV+ women with ablation‐eligible lesions by colposcopy received TA the same day (99%, 95% CI: 95%, 100%). VIA performed similarly to colposcopy in eligibility determination for TA. A single visit approach is achievable with an Xpert‐based screen‐triage‐treat strategy for ICC prevention in Malawi, a reassuring finding for HPV‐based primary screening scale‐up.

Cervical cancer screening and prevalence among older US Medicare beneficiaries with and without HIV

Abstract Females with HIV (FWH) are recommended to receive cervical cancer screening annually, with the interval extended to every 3 years after three sequential normal results. Lifelong screening is highly recommended due to their increased risk of human papillomavirus infection and cervical cancer. We assessed the trends in cervical cancer screening rates and cervical cancer/precancer prevalence among older FWH and females without HIV (FWOH) using 2007–2019 US Medicare data. We found that age‐adjusted cervical cancer screening rates decreased similarly in both FWH and FWOH (average annual percentage change: −4.4 [95% CI: −5.2, −3.6] vs. −5.7 [95% CI: −6.8, −4.7], p  = 0.11). However, the age‐adjusted cervical cancer/precancer prevalence showed increasing rates among FWH (5.4, [2.9, 7.9]) while stable in FWOH (−0.6 [−1.4, 0.1]). These findings underscore the need for strict adherence to clinical practice guidelines for cervical cancer screening in older FWH.

Epidemiological approaches to evaluate clinical unmasking of HPV ‐associated cervical lesions in the HPV vaccination era

Abstract HPV vaccination reduces the risk of developing HPV‐attributable cancers, including cervical cancer. However, an attenuation of HPV vaccine impact after the implementation of HPV vaccination may occur through clinical unmasking. Clinical unmasking is a distinct and complex phenomenon that arises in the absence of clinical interventions necessary to treat disease caused by high‐risk vaccine‐preventable HPV types (mainly HPV16) allowing uninterrupted progression of non‐vaccine preventable types that are frequently present as co‐infections. Clinical unmasking is distinct from viral unmasking, which is a diagnostic assay artifact, and from HPV type replacement, a theorized biological phenomenon requiring competition between HPV types, which has not yet been documented. All three processes could manifest as an apparent increase in cervical precancer/cancer by non‐HPV vaccine types, resulting in a lower‐than‐anticipated vaccine impact based on projections derived from type attribution studies. Here, we describe these concepts and epidemiological approaches to evaluate clinical unmasking in the post‐vaccination era. We propose a historical and a contemporaneous approach, highlighting key considerations and illustrating the potential outcomes with hypothetical data. Both approaches would have a similar outcome and interpretation: an increased incidence of precancerous lesions (CIN2+) due to non‐vaccine preventable types among vaccinated versus unvaccinated women (historically in the pre‐vaccination era, or contemporaneously) in the long term being indicative of clinical unmasking. Protection afforded by HPV vaccines against high‐grade cervical precancers, irrespective of type, remains considerable. However, carefully designed studies are needed to investigate the potential impact of clinical unmasking and its implications on vaccine effectiveness in the post‐vaccination era.

DNA methylation biomarkers for cervical cancer risk prediction in HIV‐positive Nigerian women

AbstractCervical cancer (CC) remains a significant public health issue in low‐ and middle‐income countries (LMICs), especially in Western sub‐Saharan Africa and Nigeria. While global CC incidence and mortality have declined, these regions continue to face high rates due to inadequate screening and the high prevalence of HIV, which increases CC risk by promoting persistent HPV infections. This study aimed to identify DNA methylation (DNAm) biomarkers for cervical intraepithelial neoplasia (CIN) and CC in HIV‐positive Nigerian women and to assess their potential for clinical risk prediction. From 2018 to 2020, 538 participants were recruited from Nigerian tertiary hospitals. Cervical tissue samples were analyzed for DNAm using the Infinium MethylationEPIC BeadChip array, and HPV genotyping was conducted via next‐generation sequencing. An epigenome‐wide association study revealed 24 significant DNAm biomarkers associated with CIN and CC. These biomarkers showed hypermethylation in tumor suppressor genes (e.g., PRMD8), hypomethylation in oncogenes (e.g., MIR520H), and aberrant methylation in genes related to HIV/HPV infection and oncogenesis (e.g., GNB5, LMO4, FOXK2, NMT1). A machine learning‐based DNAm classifier achieved 92.9% sensitivity and 88.6% specificity in predicting CC risk, with higher risk observed in adjacent normal cervical samples from CIN/CC patients and HIV/HPV co‐infected women. DNAm biomarkers offer a promising approach to enhancing CC screening and early detection, particularly for HIV‐positive women in LMICs. The DNAm‐based model developed in this study shows potential for more accurate CC risk stratification, highlighting the need for further optimization, validation, and implementation in low‐resource settings.

Performance of thermoablation among women treated for high‐risk human papillomavirus in a screen‐and‐treat program in South Africa

AbstractThermal ablation is a simple treatment option for HPV‐associated, pre‐cancerous disease, has a low risk of complications and can be undertaken by non‐specialists. For these reasons, it is one of the recommended treatment modalities for cervical cancer screening programs. As part of a screen‐and‐treat demonstration study, 3060 women living with and without HIV, aged 30–65 years, were recruited at an urban site in South Africa. HPV testing stratified the population into those at highest risk for precancerous disease, identifying 529 (17.3%) women with high HPV viral loads on select HPV genotypes and multi‐channel infections indicating their need for treatment. Among this group, visual assessment criteria further stratified this at‐risk population into those suitable versus unsuitable for ablative therapy. 483 (91.3%) of 529 women met visual criteria defining their suitability for ablative treatment and all were treated with thermoablation. Women were followed at 6‐ and 12‐months where HPV testing and colposcopy with histological sampling were performed. HPV persistence at 12 months despite treatment was 51.8%, and detection of histologically confirmed cervical intraepithelial neoplasia grade 2 or higher occurred in 24.0%. Being HIV‐positive, older age, multi‐channel infection, high HPV viral load, and low CD4 count were associated with these indicators of treatment failure. Cervical cancer screening programs that target treatment to the highest risk women are likely to observe higher indicators of treatment failure than less focused programs. Although thermoablation is an approved treatment modality, our results highlight the urgency of finding more effective but safe and practical treatment options for precancerous disease.

Randomized, two‐arm, noncomparative phase 2 study of olaparib plus cediranib or durvalumab in HRR‐mutated, platinum‐resistant ovarian cancer: A substudy of KGOG 3045

AbstractChoosing an optimal concomitant drug for combination with poly‐ADP ribose polymerase (PARP) inhibitor based on patient‐specific biomarker status may help increase to improve treatment efficacy in patients with ovarian cancer. However, the efficacy and safety of different PARP inhibitor‐based combinations in patients with homologous recombination repair (HRR) mutations have not been evaluated in ovarian cancer. In this sub‐study of Korean Gynecologic Oncology Group (KGOG) 3045, we compared the efficacy and safety of two olaparib‐based combinations and biomarkers of patients with platinum‐resistant ovarian cancer with HRR gene mutations. Patients were randomized to receive either olaparib (200 mg twice a day) + cediranib (30 mg daily) (Arm 1, n = 16) or olaparib (300 mg) + durvalumab (1,500 mg once every 4 weeks) (Arm 2, n = 14). The objective response rates for Arm 1 and Arm 2 were 50.0% and 42.9%, respectively. Most patients (83.3%) had BRCA mutations, which were similarly distributed between arms. Grade 3 or 4 treatment‐related adverse events were observed in 37.5% and 35.7% of the patients, respectively, but all were managed properly. A high vascular endothelial growth factor signature was associated with favorable outcomes in Arm 1, whereas immune markers (PD‐L1 expression [CPS ≥10], CD8, neutrophil‐to‐lymphocyte ratio and platelet‐to‐lymphocyte ratio) were associated with favorable outcomes in Arm 2. The activation of homologous recombination pathway upon disease progression was associated with poor response to subsequent therapy. Based on comprehensive biomarker profiling, including immunohistochemistry, whole‐exome and RNA sequencing and whole blood‐based analyses, we identified biomarkers that could help inform which of the two combination strategies is appropriate given a patient's biomarker status. Our findings have the potential to improve treatment outcome for patients with ovarian cancer in the PARP inhibitor era.

Should the age range of the Dutch hrHPV‐based cervical cancer screening program be broadened? A modelling study using cohort effects

AbstractIn the Netherlands, women are invited for human papillomavirus (HPV) screening between the ages of 30 and 60 (with conditional screening at age 65). However, an increase in cervical cancer (CC) incidence has been observed in younger women recently. Meanwhile, HPV‐vaccinated cohorts reached the screening age of 30 in 2023. Moreover, increasing healthy life expectancy is a consideration for screening in older age groups. Due to these developments, the starting and ending ages of the HPV screening programs should be reconsidered. Microsimulation model MISCAN‐Cervix was recalibrated for cohort effects using updated CC incidence data. We used this model to calculate the cost‐effectiveness of screening unvaccinated women in birth cohorts 1962–1992 until 65 years old. Additionally, we considered starting screening at 25 for partly vaccinated cohorts (born in 2002–2006). Vaccination effects were calculated using microsimulation model STDSIM. Main outcome measures included cancers prevented, life years gained (LYG), costs, and referrals compared to the current strategy (2027 onwards). Adding screening at age 65 to the current strategy leads to +3.5% cancers prevented, +10.3% referrals, +2.4% LYG and +57.0% costs (cost‐effectiveness ratio: €275,096/LYG). Adding screening at age 25 results in extra cases prevented (+1.3%–5.7%, depending on the target group's vaccination status) and LYG (+0.8%–3.7%), but increases referrals (12.9%–37.1%) and costs (+14.0%–33.1%) (cost‐effectiveness ratio: €120,017–€323,813/LYG). So, screening unvaccinated women at 65 years old and screening women in (partly‐)vaccinated cohorts at age 25 might not represent good value for money.

The prognostic impact of myosteatosis on overall survival in gynecological cancer patients: A meta‐analysis and trial sequential analysis

AbstractMyosteatosis is a novel imaging biomarker for survival in gynecological cancer patients; however, the evidence is inconsistent. This meta‐analysis aims to investigate the impact of myosteatosis on overall survival in the gynecological oncology setting. Three databases (PubMed, EMBASE and Web of Science) were systematically searched for relevant literature up to October 30, 2021. A random‐effects model was used to evaluate the predictive effect of myosteatosis on overall survival in the gynecological cancer population. The Newcastle‐Ottawa Scale was used to assess the methodological quality of the included studies. Trial sequential analysis was used to control the risk of random errors. Twelve studies with a total of 2519 patients were included. Myosteatosis was associated with a 50% increased mortality risk (HR 1.50, 95% CI 1.24‐1.82, P < .001) in gynecological cancer patients. Subgroup analyses stratified by study design, statistical model, treatment, sample size and stage confirmed the predictive value of myosteatosis on survival. However, the prognostic ability of myosteatosis only was held in the American and European populations but lost in Asians. Additionally, myosteatosis was not associated with the increased mortality in endometrial and cervical cancers, except for ovarian cancers. Overall, myosteatosis is a powerful predictor of reduced overall survival in gynecological cancer patients.

The variations in the natural history of high‐risk human papillomavirus infections in Chinese healthy women aged 27–45 years compared with 18–26 years: A prospective cohort study

AbstractData investigating the natural history of high‐risk human papillomavirus (HR‐HPV) infection in mid‐adult women compared with young adult women from regions exhibiting a bimodal distribution pattern are scarce. From November 2012 to September 2019, 3681 healthy women aged 18–45 years from the control group of a bivalent HPV vaccine Phase 3 trial in China were followed over 5.5 years. At scheduled visits (Day 0, months 7, 12, 18, 24, 30, 42, 54, and 66), cervical samples were collected for ThinPrep Pap tests and HPV DNA testing, women with abnormal cytology were referred for colposcopy. Data was analyzed using Cox regression model and a competing risk model. Sensitivity analyses were performed among participants attending all scheduled visits. The incidences of HR‐HPV persistent infections (over 6 months [6mPIs]) were 35.5 and 29.0 per 1000 person‐years (PYs) (hazard ratio [HR] = 1.21, 95% confidence interval [CI]: 1.00, 1.46), and HR‐HPV associated CIN grade 2 or greater (CIN2+) were 4.3 and 1.9 per 1000 PYs (HR = 2.31, 95% CI: 1.25, 4.26) in women aged 18–26 and 27–45 years. Competing risk models showed that the cumulative incidence of HR‐HPV infections that progressed to CIN2+ was significantly higher in women aged 18–26 than in women aged 27–45 (5.3% vs. 2.9%, Gray's test p = .0291). The cumulative clearance rates of HR‐HPV infections in women aged 18–26 and 27–45 were similar (94.7% vs. 95.8%, Gray's test p = .3309) during the study period. In conclusion, although mid‐adult women exhibit lower incidences of HR‐HPV infection and associated cervical lesions compared to young women, this population continues to face a substantial risk of acquiring causal HPV infections, which may progress to cervical lesion.

Socioeconomic position and risk of cervical cancer in the Nordic countries: Results from the Nordic Occupational Cancer Study

AbstractThe Nordic countries benefited from declines in cervical cancer incidence rates due to the implementation of screening programmes. However, it is unclear whether all social groups have equally benefited from these preventive services. We provide an assessment of the temporal trends in cervical cancer incidence by socioeconomic position (SEP) in Denmark, Norway, Finland and Sweden, using data from the Nordic Occupational Cancer Study. Truncated age‐standardized incidence rates and 95% confidence intervals (CI) of cervical cancer per 100,000 person‐years were computed for women aged 50–69 by SEP and country within the period 1961–2005. We used Poisson regression models to compute relative risks (RRs) and 95% CIs of cervical cancer across SEP, pooling data for the three most recent 5‐year periods (except for Denmark 1991–1995 and Norway 1991–2003). Throughout the study period, declines in the rates of cervical cancer were observed among all SEP groups. Lower SEP rates, which started from higher values, declined faster than those for higher SEP. At the conclusion of the study period, we still observed a social gradient, with higher rates seen in lower SEP women. Farmers had the lowest risk in all four countries. The RRs for lowest versus highest SEP ranged from 1.33 (95% CI 1.05–1.69) in Sweden to 1.76 (95% CI 1.13–2.85) in Denmark, with a pooled RR of 1.41 (95% CI 1.22–1.64). Lower SEP women still face the highest risks, indicating a need for continued efforts to provide equitable access to preventive services.

Global landscape of cervical cancer incidence and mortality in 2022 and predictions to 2030: The urgent need to address inequalities in cervical cancer

AbstractCervical cancer remains a major public health challenge worldwide, despite being largely preventable through effective interventions. Timely evidence regarding the global landscape of cervical cancer is crucial for measuring the magnitude of inequalities and monitoring progress towards cervical cancer elimination. We aimed to provide an updated overview of the global burden of cervical cancer using the GLOBOCAN 2022 database. Age‐standardized rates of incidence and mortality were presented according to countries, 20 United Nations‐defined world regions, and four‐tier Human Development Index (HDI) levels. The predicted burden of cervical cancer for 2030 was calculated based on global demographic projections. Globally, an estimated 662,301 new cervical cancer cases and 348,874 deaths occurred in 2022. Substantial geographic disparities in cervical cancer burden existed across countries and world regions. Low HDI countries exhibited two times higher incidence rates and five times higher mortality rates, compared to very high HDI countries. For women aged 15–44 years, cervical cancer ranked among the top three most frequent cancers in 149 countries, and among the top three causes of cancer deaths in 154 countries. If 2022 rates remain unchanged, the global burden of cervical cancer was predicted to increase to 760,082 new cases (a 14.8% increase) and 411,035 deaths (a 17.8% increase) by 2030. Our findings highlight the persistent and widening geographic and socioeconomic inequalities in the burden of cervical cancer. There is an urgent need for tailored national strategies to address these inequalities and accelerate progress towards the goal of cervical cancer elimination.

Targeted DNA sequencing of high‐grade serous ovarian carcinoma reveals association of TP53 mutations with platinum resistance when combined with gene expression

AbstractHigh‐grade serous ovarian carcinoma (HGSC) is the most common subtype of ovarian cancer and is among the most fatal gynecological malignancies worldwide, due to late diagnosis at advanced stages and frequent therapy resistance. In 47 HGSC patients, we assessed somatic and germline genetic variability of a custom panel of 144 known or suspected HGSC‐related genes by high‐coverage targeted DNA sequencing to identify the genetic determinants associated with resistance to platinum‐based therapy. In the germline, the most mutated genes were DNAH14 (17%), RAD51B (17%), CFTR (13%), BRCA1 (11%), and RAD51 (11%). Somatically, the most mutated gene was TP53 (98%), followed by CSMD1/2/3 (19/19/36%), and CFTR (23%). Results were compared with those from whole exome sequencing of a similar set of 35 HGSC patients. Somatic variants in TP53 were also validated using GENIE data of 1287 HGSC samples. Our approach showed increased prevalence of high impact somatic and germline mutations, especially those affecting splice sites of TP53, compared to validation datasets. Furthermore, nonsense TP53 somatic mutations were negatively associated with patient survival. Elevated TP53 transcript levels were associated with platinum resistance and presence of TP53 missense mutations, while decreased TP53 levels were found in tumors carrying mutations with predicted high impact, which was confirmed in The Cancer Genome Atlas data (n = 260). Targeted DNA sequencing of TP53 combined with transcript quantification may contribute to the concept of precision oncology of HGSC. Future studies should explore targeting the p53 pathway based on specific mutation types and co‐analyze the expression and mutational profiles of other key cancer genes.

Low methylation marker levels among human papillomavirus‐vaccinated women with cervical high‐grade squamous intraepithelial lesions

AbstractCervical cancer screening programs, including triage tests, need redesigning as human papillomavirus (HPV)‐vaccinated women are entering the programs. Methylation markers offer a potential solution to reduce false‐positive rates by identifying clinically relevant cervical lesions with progressive potential. In a nested case–control study, 9242 women who received the three‐dose HPV16/18‐vaccine at ages 12–15 or 18 in a community‐randomized trial were included. Subsequently, they were re‐randomized for either frequent or infrequent cervical cancer screening trials. Over a 15‐year post‐vaccination follow‐up until 2022, 17 high‐grade squamous intraepithelial lesion (HSIL) and 15 low‐grade (LSIL) cases were identified at the 25‐year screening round, alongside 371 age and community‐matched HPV16/18‐vaccinated controls. Methylation analyses were performed on cervical samples collected at age 25, preceding histologically confirmed LSIL or HSIL diagnoses. DNA methylation of viral (HPV16/18/31/33) and host‐cell genes (EPB41L3, FAM19A4, and miR124‐2) was measured, along with HPV‐genotyping. No HPV16/18 HSIL cases were observed. The predominant HPV‐genotypes were HPV52 (29.4%), HPV59/HPV51/HPV58 (each 23.5%), and HPV33 (17.7%). Methylation levels were generally low, with no significant differences in mean methylation levels of viral or host‐cell genes between the LSIL/HSIL and controls. However, a significant difference in methylation levels was found between HSIL cases and controls when considering a combination of viral genes and EPB41L3 (p value = .0001). HPV‐vaccinated women with HSIL had HPV infections with uncommon HPV types that very rarely cause cancer and displayed low methylation levels. Further investigation is warranted to understand the likely regressive nature of HSIL among HPV‐vaccinated women and its implications for management.

HPV vaccination is highly effective and cost‐effective for cervical cancer prevention in women living with HIV in China: A cost‐effectiveness analysis

AbstractThe presence of human immunodeficiency virus (HIV) infection increases the risk of acquiring human papillomavirus (HPV) infection and developing HPV‐related adversities. We aimed to estimate the cost‐effectiveness of HPV vaccination for women living with HIV in a Chinese setting. A decision‐analysis Markov model was developed to estimate the cost‐effectiveness of 36 HPV vaccination strategies for women living with HIV aged 18–45 years, from the healthcare system perspective. With the status quo, not vaccinating women living with HIV would lead to 51.99% (51,985/100,000) HIV‐related deaths; 35.10% (35,098/100,000) would develop genital warts, 0.36% (355/100,000) develop cervical cancer, and among which 63.66% (226/355) die from cervical cancer over their lifetime (1,601,457 person‐years). With a willingness to pay (WTP) threshold of three times gross domestic product (GDP), Gardasil 4 vaccination for all women living with HIV aged 18–45 years was the most cost‐effective strategy (ICER = US $32,766/QALY gained). This strategy would reduce genital warts by 35.52% (12,467/35,098), cervical cancers by 12.96% (46/355), and cervical cancer deaths by 12.39% (28/226) over the lifetime of the cohort. If the future domestic Cecolin 9 vaccine is priced at 60% of Gardasil 9, vaccinating all women living with HIV aged 18–45 years with Cecolin 9 would be the most cost‐effective strategy (ICER = US $30,493/QALY gained). Improving adherence to antiretroviral therapy for HIV may substantially improve the cost‐effectiveness of both Gardasil 4 and Cecolin 9 vaccination.

Exposure to polycyclic aromatic hydrocarbons promotes the progression of low‐grade cervical intraepithelial neoplasia: A population‐based cohort study in China

AbstractLow‐grade cervical intraepithelial neoplasia (CIN1) is an early stage of cervical cancer development. Previously, we reported that exposure to polycyclic aromatic hydrocarbons (PAHs) increases the risk of cervical precancerous lesions, especially in females with a high‐risk human papillomavirus (HR‐HPV) infection. However, the effects of PAHs on CIN1 progression remain unclear. A community‐based prospective cohort study was conducted to evaluate the role of exposure to PAHs in the progression of CIN1. A total of 564 patients diagnosed with CIN1 were followed‐up at 6, 12, and 24 months, post‐diagnosis, to determine CIN1 reversion, persistence, and progression. Exposure to PAHs was determined by the urine 1‐hydroxipayrene (1‐OHP) level. Our results showed that the 1‐OHP level was significantly higher in patients with CIN1 persistence/progression than in those with reversion (P < .05). High exposure to PAHs increased the risk of CIN1 persistence/progression, with hazard ratios (HR), 95% confidence intervals (CI) of (1.62, 1.24–2.67), (1.98, 1.42–2.75), and (2.37, 1.61–3.49) at 6, 12, and 24 months, post‐diagnosis, respectively. The effect was enhanced with HR‐HPV positivity, as determined at 6 (1.82, 1.24–2.67), 12 (3.02, 1.74–5.23), and 24 (2.51, 1.48–4.26) months, post‐diagnosis. Moreover, the predictive value of exposure to PAHs for CIN1 persistence/progression was higher in HR‐HPV‐positive patients than in HR‐HPV‐negative patients. The results revealed that exposure to PAHs facilitated the malignant progression of CIN1 and hindered its reversal, particularly in patients with HR‐HPV infection. Our findings provide novel insights into early prevention and intervention targeting the initiation and progression of cervical neoplasia.

Effectiveness of self‐sampling human papillomavirus test on precancer detection and screening uptake in Japan: The ACCESS randomized controlled trial

AbstractJapan is lagging in cervical cancer prevention. The effectiveness of a self‐sampling human papillomavirus (HPV) test, a possible measure to overcome this situation, has not yet been evaluated. A randomized controlled trial was performed to evaluate the effectiveness of a self‐sampling HPV test on detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and screening uptake. Women between 30 and 58 years old who did not participate in the cervical cancer screening program for ≥3 years were eligible and assigned to the intervention group (cytology or self‐sampling HPV test) or control group (cytology). Participants assigned to the intervention group were sent a self‐sampling kit according to their ordering (opt‐in strategy). A total of 7337 and 7772 women were assigned to the intervention and control groups, respectively. Screening uptake in the intervention group was significantly higher than that in the control group (20.0% vs. 6.4%; risk ratio: 3.10; 95% confidence interval [CI]: 2.82, 3.42). The compliance rate with cytology triage for HPV‐positive women was 46.8% (95% CI: 35.5%, 58.4%). CIN2+ was detected in five and four participants in the intervention and control groups, respectively; there was no difference for intention‐to‐screen analysis (risk ratio: 1.32; 95% CI: 0.36, 4.93). Self‐sampling of HPV test increased screening uptake; however, no difference was observed in the detection of CIN2+, probably due to the low compliance rate for cytology triage in HPV‐positive women. Efforts to increase cytology triage are essential to maximize precancer detections.

Reduced adherence to cervical cancer screening. The importance of information and education for women with low education and low‐income

Characterization of ovarian cancer survival by histotype and stage: A nationwide study in Norway

AbstractContemporary population‐based data on ovarian cancer survival using current subtype classifications and by surgical status are sparse. We evaluated 1‐, 3‐, 5‐ and 7‐year relative (and overall) survival, and excess hazards in patients with borderline tumors or invasive epithelial ovarian cancer diagnosed 2012 to 2021 in a nationwide registry‐based cohort in Norway. Outcomes were evaluated by histotype, FIGO stage, cytoreduction surgery and residual disease. Overall survival was evaluated for non‐epithelial ovarian cancer. Survival of women with borderline ovarian tumors was excellent (≥98.0% 7‐year relative survival). Across all evaluated invasive epithelial ovarian cancer histotypes, 7‐year relative survival for cases diagnosed with stages I or II disease was ≥78.3% (stage II high‐grade serous). Survival for ovarian cancers diagnosed at stage ≥III differed substantially by histotype and time since diagnosis (eg, stage III, 5‐year relative survival from 27.7% [carcinosarcomas] to 76.2% [endometrioid]). Overall survival for non‐epithelial cases was good (91.8% 5‐year overall survival). Women diagnosed with stage III or IV invasive epithelial ovarian cancer and with residual disease following cytoreduction surgery had substantially better survival than women not operated. These findings were robust to restriction to women with high reported functional status scores. Patterns for overall survival were similar to those for relative survival. We observed relatively good survival with early stage at diagnosis even for the high grade serous histotype. Survival for patients diagnosed at stage ≥III invasive epithelial ovarian cancer was poor for all but endometrioid disease. There remains an urgent need for strategies for risk reduction and earlier detection, together with effective targeted treatments.

Olaparib efficacy in patients with germline BRCA ‐mutated, HER2 ‐negative metastatic breast cancer: Subgroup analyses from the phase III OlympiAD trial

Abstract In the primary analysis of the phase III OlympiAD trial, olaparib significantly prolonged progression‐free survival (PFS) vs chemotherapy treatment of physician's choice (TPC) in patients with germline BRCA‐mutated (gBRCAm), HER2‐negative metastatic breast cancer (mBC). We report subgroup analyses for the final analysis at a median OS follow‐up of 18.9 months (olaparib) and 15.5 months (TPC). Patients (N = 302) with gBRCAm, HER2‐negative mBC and ≤2 previous lines of chemotherapy for mBC were randomized 2:1 to open‐label olaparib (300 mg twice daily) or TPC. All subgroup analyses were prespecified except site of metastases. Investigator‐assessed median PFS was 8.0 months (95% confidence interval [CI] 5.8‐8.4; 176/205 events) for olaparib and 3.8 months (95% CI 2.8‐4.2; 83/97 events) for TPC (hazard ratio 0.51, 95% CI 0.39‐0.66). In subgroup analyses, median PFS hazard ratios (95% CI) favored olaparib: hormone receptor status (triple‐negative: 0.47, 0.32‐0.69; hormone receptor‐positive: 0.52, 0.36‐0.75); gBRCAm ( BRCA1 : 0.49, 0.35‐0.71; BRCA2 : 0.49, 0.33‐0.74); site of metastases (visceral/CNS: 0.53, 0.40‐0.71; non‐visceral: 0.45, 0.23‐0.98); prior chemotherapy for mBC (yes: 0.51, 0.38‐0.70; no: 0.49, 0.30‐0.82); prior platinum‐based chemotherapy for BC (yes: 0.49, 0.30‐0.83; no: 0.50, 0.37‐0.69); progressive disease at randomization (yes: 0.48, 0.35‐0.65; no: 0.61, 0.36‐1.07). Investigator‐assessed objective response rates were higher across all subgroups with olaparib (35‐68%) vs TPC (5‐40%). Global health status/health‐related quality of life increased in all subgroups with olaparib vs decreased/no change with TPC. These data confirm the consistency of olaparib benefit across patient subgroups in OlympiAD.

Unveiling the epigenomic mechanisms of acquired platinum‐resistance in high‐grade serous ovarian cancer

AbstractResistance to platinum‐based chemotherapy is the major cause of death from high‐grade serous ovarian cancer (HGSOC). We hypothesise that detection of specific DNA methylation changes may predict platinum resistance in HGSOC. Using a publicly available “discovery” dataset we examined epigenomic and transcriptomic alterations between primary platinum‐sensitive (n = 32) and recurrent acquired drug resistant HGSOC (n = 28) and identified several genes involved in immune and chemoresistance‐related pathways. Validation via high‐resolution melt analysis of these findings, in cell lines and HGSOC tumours, demonstrated the most consistent changes were observed in three of the genes: APOBEC3A, NKAPL and PDCD1. Plasma samples from an independent HGSOC cohort (n = 17) were analysed using droplet digital PCR. Hypermethylation of NKAPL was detected in 46% and hypomethylation of APOBEC3A in 69% of plasma samples taken from women with relapsed HGSOC (n = 13), with no alterations identified in disease‐free patients (n = 4). Following these results, and using a CRISPR‐Cas9 approach, we were also able to demonstrate that in vitro NKAPL promoter demethylation increased platinum sensitivity by 15%. Overall, this study demonstrates the importance of aberrant methylation, especially of the NKAPL gene, in acquired platinum resistance in HGSOC.

Cost‐effectiveness of primary human papillomavirus triage approaches among vaccinated women in Norway: A model‐based analysis

AbstractAs Norway considers revising triage approaches following their first adolescent cohort with human papillomavirus (HPV) vaccination entering the cervical cancer screening program, we analyzed the health impact and cost‐effectiveness of alternative primary HPV triage approaches for women initiating cervical cancer screening in 2023. We used a multimodeling approach that captured HPV transmission and cervical carcinogenesis to evaluate the health benefits, harms and cost‐effectiveness of alternative extended genotyping and age‐based triage strategies under five‐yearly primary HPV testing (including the status‐quo screening strategy in Norway) for women born in 1998 (ie, age 25 in 2023). We examined 35 strategies that varied alternative groupings of high‐risk HPV genotypes (“high‐risk” genotypes; “medium‐risk” genotypes or “intermediate‐risk” genotypes), number and types of HPV included in each group, management of HPV‐positive women to direct colposcopy or active surveillance, wait time for re‐testing and age at which the HPV triage algorithm switched from less to more intensive strategies. Given the range of benchmarks for severity‐specific cost‐effectiveness thresholds in Norway, we found that the preferred strategy for vaccinated women aged 25 years in 2023 involved an age‐based switch from a less to more intensive follow‐up algorithm at age 30 or 35 years with HPV‐16/18 genotypes in the “high‐risk” group. The two potentially cost‐effective strategies could reduce the number of colposcopies compared to current guidelines and simultaneously improve health benefits. Using age to guide primary HPV triage, paired with selective HPV genotype and follow‐up time for re‐testing, could improve both the cervical cancer program effectiveness and efficiency.

Scientific approaches toward improving cervical cancer elimination strategies

AbstractAt the 2023 EUROGIN workshop scientific basis for strategies to accelerate the elimination of cervical cancer and its causative agent, human papillomavirus (HPV) were reviewed. Although some countries have reached key performance indicators toward elimination (>90% of girls HPV vaccinated and >70% of women HPV screened), most are yet to reach these targets, implying a need for improved strategies. Gender‐neutral vaccination, even with moderate vaccination coverage was highlighted as a strategy to achieve elimination more rapidly. It is more resilient against major disturbances in vaccination delivery, such as what happened during the coronavirus pandemic. Further, an analysis of ethical/legal issues indicated that female‐restricted vaccination is problematic. Extended catch‐up of vaccination with concomitant screening, and outreach to vulnerable groups were highlighted. Although birth cohorts with high coverage of HPV vaccination at school are protected against HPV, and HPVs have a very low reproductive rate in women above age 35, adult women below age 30 have inadequate direct protection. In addition to herd protection from gender‐neutral vaccination, this group can be protected by offering concomitant catch‐up HPV vaccination and HPV screening. Furthermore, hepatitis B vaccination experiences indicate that elimination cannot be achieved without prioritizing vulnerable/migrant populations. The long‐lasting durability of vaccination‐induced antibody responses suggests prolonged protection with HPV vaccines when adequately administrated. Finally, cost‐effectiveness modelling suggests that high‐coverage HPV vaccination in multiple population segments will be resource‐saving due to reduced need for screening. In summary, the workshop found that strategically optimal deployment of vaccination will accelerate elimination of HPV and cervical cancer.

Performance of the WID‐qEC test to detect uterine cancers in black women with abnormal uterine bleeding: A prospective observational cohort study in Ghana

AbstractThe burden of uterine cancer is growing and, in the US and UK, mortality rates are poorest among black women. Early detection of these cancers is critical and poor performance of ultrasound in black women may contribute to adverse outcomes. Limited data on this topic are available from Africa. We assessed whether a simple DNA methylation test, the WID‐qEC, enables detection of all epithelial uterine (endometrial and cervical) cancers in women presenting with abnormal uterine bleeding (AUB) in Ghana. Among 118 women ≥40 years presenting with AUB, 106 consented to the study and a cervicovaginal sample was obtained for WID‐qEC testing. Subsequent to ultrasound assessment 102 women had a cervical or endometrial biopsy. Histopathology, ultrasound and WID‐qEC testing were analyzed and compared. Among the 102 volunteers, 8 and 15 were diagnosed with endometrial and cervical cancer (EC and CC), respectively. The receiver operating characteristic (ROC) area under the curve (AUC) was 0.56 (95% confidence interval [CI] 0.25–0.86) for sonographic endometrial thickness (ET) and 0.98 (95% CI 0.94–1.00) for the WID‐qEC test. Sensitivity and specificity of the prespecified ET ≥5 mm were 66.7% (95% CI 24.1–94.0) and 22.7 (95% CI 12.0–38.2) and for the prespecified WID‐qEC SUM‐PMR ≥ 0.3 were 100% (95% CI 56.1–100.0) and 76.1 (96%CI 60.9–86.9), respectively. In addition, 15 CCs were detected by the WID‐qEC test [sensitivity 100% (95% CI 74.7–100.0)]. The WID‐qEC test accurately detects both EC and CC in black women presenting with AUB.

TP53 mutations and survival in ovarian carcinoma patients receiving first‐line chemotherapy plus bevacizumab: Results of the MITO16A/MaNGO OV‐2 study

AbstractTo date, there are no biomarkers that define a patient subpopulation responsive to bevacizumab (BEV), an effective treatment option for advanced ovarian carcinoma (OC). In the context of the MITO16A/MaNGO OV‐2 trial, a Phase IV study of chemotherapy combined with BEV in first‐line treatment of advanced OC, we evaluated TP53 mutations by next‐generation sequencing and p53 expression by immunohistochemistry (IHC) on 202 and 311 cases, respectively. We further correlated TP53 mutations in terms of type, function, and site, and IHC data with patients' clinicopathological characteristics and survival. TP53 missense mutations of unknown function (named unclassified) represented the majority of variants in our population (44.4%) and were associated with a significantly improved overall survival (OS) both in univariable (hazard ratio [HR] = 0.43, 95% confidence interval [CI] = 0.20–0.92, p = .03) and multivariable analysis (HR = 0.39, 95% CI = 0.18–0.86, p = .02). Concordance between TP53 mutational analysis and IHC was 91%. We observed an HR of 0.70 for OS in patients with p53 IHC overexpression compared to p53 wild‐type, which however did not reach statistical significance (p = .31, 95% CI = 0.36–1.38). Our results indicate that the presence of unclassified TP53 mutations has favorable prognostic significance in patients with OC receiving upfront BEV plus chemotherapy. In particular, unclassified missense TP53 mutations characterize a subpopulation of patients with a significant survival advantage, independently of clinicopathological characteristics. Our findings warrant future investigations to confirm the prognostic impact of TP53 mutations in BEV‐treated OC patients and deserve to be assessed for their potential predictive role in future randomized clinical studies.

Clinical performance of the novel full‐genotyping OncoPredict HPV Quantitative Typing assay using the VALGENT framework

AbstractClinical validation of human papillomavirus (HPV) assays according to international criteria is prerequisite for their implementation in cervical cancer screening. OncoPredict HPV Quantitative Typing (QT) assay (Hiantis Srl, Milan, Italy) is a novel full‐genotyping multiplex real‐time PCR quantitative assay targeting E6/E7 genes, allowing individual viral load determination of 12 high‐risk (HR) HPV types. Quality controls for sample adequacy, efficiency of nucleic acid extraction and PCR inhibition are included in the assay. Clinical performance of OncoPredict HPV QT test was assessed as part of the “Validation of HPV Genotyping Tests” (VALGENT‐2) framework, consisting of 1300 cervical liquid‐based cytology (LBC) samples of women aged between 20 and 60 years who had originally attended for routine cervical screening in Scotland. The clinical accuracy of the OncoPredict HPV QT (index test) for the detection of CIN2+ was assessed relative to the GP5+/6+ Enzyme ImmunoAssay (GP5+/6+ EIA) (comparator test), using noninferiority criteria. Intra‐ and interlaboratory reproducibility of the assay was assessed on a subpopulation, comprising 526 samples. The relative sensitivity and specificity for OncoPredict HPV QT vs GP5+/6+‐PCR‐EIA were 1.01 (95% CI: 0.99‐1.03) and 1.03 (95% CI: 1.0‐1.06) respectively. The P‐values for noninferiority were ≤0.001. The intra‐ and inter‐laboratory reproducibility demonstrated a high concordance (>98.7%) with kappas for individual types ranging from 0.66 to 1.00. OncoPredict HPV QT fulfills the international validation criteria for the use of HPV tests in cervical cancer screening.

A rapid HPV typing assay to support global cervical cancer screening and risk‐based management: A cross‐sectional study

AbstractThe World Health Organization recommends human papillomavirus (HPV) testing for cervical screening. Extended genotyping can identify the highest‐risk HPV‐positive women. An inexpensive, rapid, mobile isothermal amplification assay (ScreenFire HPV RS test) was recently redesigned to yield four channels ordered by cancer risk (ie, hierarchical approach): HPV16, HPV18/45, HPV31/33/35/52/58 and HPV39/51/56/59/68. Stored specimens from 2076 women (mean age 30.9) enrolled in a colposcopy clinic, with high HPV prevalence, were tested with ScreenFire. We calculated hierarchical channel positivity and non‐hierarchical channel and type positivity, according to histologic diagnosis (256 cancer, 350 cervical intraepithelial neoplasia [CIN]3, 409 CIN2, 1020 < CIN2) and known virologic reference results (Linear Array and TypeSeq). Additionally, we analyzed ScreenFire time‐to‐positive up to 60 min by channel and histology. Overall clinical sensitivity for CIN3+ was 94.7% (95% confidence interval 92.6‐96.4), similar to Linear Array (92.3, 89.7‐94.3) and TypeSeq (96.0, 93.9‐97.6). Sensitivity was high for all types and channels. The hierarchical approach was well in line with HPV typing and histologic diagnosis, prioritizing higher risk women having HPV16 and precancer. For HPV16, time‐to‐positive was shorter in women with precancer. ScreenFire showed excellent agreement with research reference typing tests and detection of CIN2+. Risk‐based type results could help guide clinical management of HPV‐positive women. Time‐to‐positive combined with genotyping might be useful. ScreenFire is rapid, mobile, relatively inexpensive and designed for implementation of HPV‐based screening and management, including in lower‐resource settings. Further validation in screening by self‐sampling and practical effectiveness merit evaluation.

Long‐term follow‐up of cervical cancer incidence after normal cytological findings

AbstractAn increase in cervical cancer incidence in Sweden from 2014 to 2015 has been attributed to an increase in false‐negative cytological findings before cancer diagnoses. Years later, we performed a long‐term follow‐up to investigate whether the problem persisted. At each calendar year from 2016 to 2020, we identified women with prior normal cervical screening results through linkage to the Swedish National Cervical Screening Registry. We reported their incidence rates (IRs) of invasive cervical cancer in consecutive years and compared the IRs over time. For the years 2016 to 2020, there was no overall change in cervical cancer incidence after two normal cytology in the last two screening intervals. However, there was a further 62% increase among women 50 to 60 years of age with normal cytology in the past two screening intervals. The incidence rate of cervical cancer was high among nonscreened women and low among HPV‐screened women with negative results, with no trends over time. Our results imply that the previously reported decrease in sensitivity of cervical cytology is persisting. Although primary cytology screening is no longer used, cytology is used in triaging among HPV‐positive women. Our findings suggest that improved triaging is needed, for example, improved quality assurance and/or use of alternative triage tests.

Cervical precancer and cancer incidence among insured women with and without HIV in South Africa

AbstractHIV infection increases the risk of developing cervical cancer; however, longitudinal studies in sub‐Saharan Africa comparing cervical cancer rates between women living with HIV (WLWH) and women without HIV are scarce. To address this gap, we compared cervical precancer and cancer incidence rates between WLWH and women without HIV in South Africa using reimbursement claims data from a medical insurance scheme from January 2011 to June 2020. We used Royston‐Parmar flexible parametric survival models to estimate cervical precancer and cancer incidence rates as a continuous function of age, stratified by HIV status. Our study population consisted of 518 048 women, with exclusions based on the endpoint of interest. To analyse cervical cancer incidence, we included 517 312 women, of whom 564 developed cervical cancer. WLWH had an ~3‐fold higher risk of developing cervical precancer and cancer than women without HIV (adjusted hazard ratio for cervical cancer: 2.99; 95% confidence interval [CI]: 2.40‐3.73). For all endpoints of interest, the estimated incidence rates were higher in WLWH than women without HIV. Cervical cancer rates among WLWH increased at early ages and peaked at 49 years (122/100 000 person‐years; 95% CI: 100‐147), whereas, in women without HIV, incidence rates peaked at 56 years (40/100 000 person‐years; 95% CI: 36‐45). Cervical precancer rates peaked in women in their 30s. Analyses of age‐specific cervical cancer rates by HIV status are essential to inform the design of targeted cervical cancer prevention policies in Southern Africa and other regions with a double burden of HIV and cervical cancer.

Performance of the HPV E6/E7 mRNA Aptima HPV assay combined with partial genotyping compared with the HPV DNA Cobas 4800 HPV test for use in primary screening: Results from the CERVIVA HPV primary screening study in Ireland

AbstractThere are currently several validated HPV tests. However, longitudinal data which spans appropriate age ranges, as well as evaluation of potential screening algorithms are necessary for screening programmes choice of test. The objective of our study was to evaluate the performance of HPV mRNA and HPV DNA testing, including partial genotyping, in routine cervical screening. As part of the CERVIVA HPV Primary Screening Study, ThinPrep samples from 10 150 women were tested for HPV mRNA using the Aptima HPV assay and HPV DNA using the Cobas 4800 HPV test. HPV mRNA‐positive women were further assessed with the Aptima genotyping assay for HPV 16/18/45. Baseline cytology and prospective follow‐up data were collected. The performance of the two tests was examined over 42 months (to date). HPV mRNA demonstrated equivalent sensitivity to HPV DNA testing for detection of CIN2+ (93.2% [92.4‐93.9] vs 92.8% [92.0‐93.6], respectively) and CIN3+ (94.6% [93.8‐95.3] vs 94.6% [93.8‐95.3]). HPV mRNA testing had significantly higher specificity compared to HPV DNA for detection of CIN2+ (84.0% [83.5‐84.5] vs 80.8% [80.2‐81.4], respectively) and CIN3+ (88.44% [88.2‐88.6] vs 85.62 [85.4‐85.9]). The proportion of CIN2+ and CIN3+, over 3 years (42 months), in HPV‐negative women was comparable for both RNA (0.20% and 0.10%) and DNA (0.22% and 0.11%). Genotyping data was comparable across both assay platforms. In the context of HPV primary screening HPV mRNA testing has potential to reduce triage tests and follow‐up tests at 12 months compared to DNA testing, with no significant difference in detection of CIN2+ and CIN3+.

Validation of novel DNA methylation markers in cervical precancer and cancer

AbstractWe have recently identified, using a genome‐wide approach, new methylation markers which were evaluated among various cervical intraepithelial neoplasia (CIN) grades and cervical cancer. We herein validate the methylated state of these genes in independent study populations, based on histology ascertained outcomes regardless of human papillomavirus status. CA10, DPP10, FMN2 and HAS1 (discovery set: 54 normal, 50 CIN1, 40 CIN2, 42 CIN3) were evaluated by targeted bisulfite next generation sequencing (NGS) (Illumina MiSeq platform) in 258 (training set: 100 normal, 50 CIN1, 50 CIN2, 50 CIN3, 8 cancers) and 373 (validation set: 100 normal, 57 CIN1, 61 CIN2, 53 CIN3, 102 cancers) physician‐collected samples (PreservCyt). Using targeted amplification NGS data from the training set for 94 normal and eight cancer samples, we calculated for each gene the median methylation value. These were summed and normalized to compute a four‐gene Marker Polygenic Score (MPS). We compared the relationship between MPS and progression from normal through CIN grades and cancer, separately in the training and validation sets, and tested its clinical performance via receiver‐operating characteristic curves. MPS increased with increasing CIN grade, and accurately predicted cervical cancer in the training (area under the curve, AUC = 0.9950) and validation (AUC = 0.9337) sets, comparing normal to cancer. Using the highest threshold of 100% specificity, sensitivity for detection of cervical cancer was 67.7%; whereas reducing specificity to 95% increased sensitivity to 84.3%. Further evaluation of these biomarkers is warranted in prospective studies.

Methylation testing for the detection of recurrent cervical intraepithelial neoplasia

AbstractWomen treated for CIN2/3 remain at increased risk of recurrent CIN and cervical cancer, and therefore posttreatment surveillance is recommended. This post hoc analysis evaluates the potential of methylation markers ASCL1/LHX8 and FAM19A4/miR124‐2 for posttreatment detection of recurrent CIN2/3. Cervical scrapes taken at 6 and 12 months posttreatment of 364 women treated for CIN2/3 were tested for methylation of ASCL1/LHX8 and FAM19A4/miR124‐2 using quantitative multiplex methylation‐specific PCR. Performance of the methylation tests were calculated and compared with the performance of HPV and/or cytology. Methylation levels of recurrent CIN were compared between women with a persistent HPV infection, and women with an incident HPV infection or without HPV infection. Recurrent CIN2/3 was detected in 42 women (11.5%), including 28 women with CIN2 and 14 with CIN3. ASCL1/LHX8 tested positive in 13/14 (92.9%) of recurrent CIN3 and 13/27 (48.1%) of recurrent CIN2. FAM19A4/miR124‐2 tested positive in 14/14 (100%) of recurrent CIN3 and 10/27 (37.0%) of recurrent CIN2. Combined HPV and/or methylation testing showed similar positivity rates as HPV and/or cytology. The CIN2/3 risk at 12 months posttreatment was 30.8% after a positive ASCL1/LHX8 result at 6 months posttreatment. Methylation levels of CIN2/3 in women with a persistent HPV infection were significantly higher compared with women with an incident or no HPV infection. In conclusion, posttreatment monitoring by methylation analysis of ASCL1/LHX8 and FAM19A4/miR124‐2 showed a good performance for the detection of recurrent CIN. DNA methylation testing can help to identify women with recurrent CIN that require re‐treatment.

Cause‐specific mortality after diagnosis of cancer among HIV‐positive patients: A collaborative analysis of cohort studies

People living with HIV (PLHIV) are more likely than the general population to develop AIDS‐defining malignancies (ADMs) and several non‐ADMs (NADMs). Information is lacking on survival outcomes and cause‐specific mortality after cancer diagnosis among PLHIV. We investigated causes of death within 5 years of cancer diagnosis in PLHIV enrolled in European and North American HIV cohorts starting antiretroviral therapy (ART) 1996–2015, aged ≥16 years, and subsequently diagnosed with cancer. Cancers were grouped: ADMs, viral NADMs and nonviral NADMs. We calculated cause‐specific mortality rates (MR) after diagnosis of specific cancers and compared 5‐year survival with the UK and France general populations. Among 83,856 PLHIV there were 4,436 cancer diagnoses. Of 603 deaths after ADM diagnosis, 292 (48%) were due to an ADM. There were 467/847 (55%) and 74/189 (39%) deaths that were due to an NADM after nonviral and viral NADM diagnoses, respectively. MR were higher for diagnoses between 1996 and 2005 versus 2006–2015: ADMs 102 (95% CI 92–113) per 1,000 years versus 88 (78–100), viral NADMs 134 (106–169) versus 111 (93–133) and nonviral NADMs 264 (232–300) versus 226 (206–248). Estimated 5‐year survival for PLHIV diagnosed with liver (29% [19–39%]), lung (18% [13–23%]) and cervical (75% [63–84%]) cancer was similar to general populations. Survival after Hodgkin's lymphoma diagnosis was lower in PLHIV (75% [67–81%]). Among ART‐treated PLHIV diagnosed with cancer, MR and causes of death varied by cancer type, with mortality highest for liver and lung cancers. Deaths within 5 years of NADM diagnoses were more likely to be from cancer than AIDS.

Specialist oncological surgery for removal of the ovaries and fallopian tubes in BRCA1 and BRCA2 pathogenic variant carriers may reduce primary peritoneal cancer risk to very low levels

AbstractRisk‐reducing bilateral salpingo‐oophorectomy (RRBSO) is highly effective for the prevention of high‐grade serous ovarian cancer (HGSOC) in BRCA1/2 pathogenic variant carriers (PVCs), but does not completely eliminate future risk of primary peritoneal cancer (PPC). The requirement to completely remove fallopian tubes at RRBSO and carefully exclude occult cancer/serous tubal intraepithelial carcinoma (STIC) lesions may not have been appreciated historically. We calculated rates of HGSOC and PPC in confirmed BRCA1/2 PVCs registered on the regional database in those who did (cases) and did not (controls) undergo RRBSO after genetic testing. Expected annual rates of ovarian/peritoneal cancer were 1% for BRCA1 ≥ 35 years and 0.5% for BRCA2 ≥ 45 years. Follow‐up before 35/45 years was “risk free” and lead time excluded RRBSO <35 years and <45 years for BRCA1 and BRCA2, respectively. Women were followed from personal mutation report (controls) or RRBSO (cases) to death, ovarian/peritoneal cancer or last follow‐up, whichever was sooner. In total, 891 cases (BRCA1 = 468, BRCA2 = 423) and 1302 controls had follow‐up ≥35 years (BRCA1 = 736) and ≥45 years (BRCA2 = 566), respectively, over a total of 7261.1 risk eligible years (mean = 8.15 years). Twenty‐one occult ovarian cancers were found at RRBSO (2.4%), 16 at stage 1. Post RRBSO, 56.97 ovarian/peritoneal cancers were expected but only 3 were observed (HR = 0.053; 95% CI = 0.013‐0.14), with combined Kaplan‐Meier analysis HR = 0.029 (95% CI = 0.009‐0.100, P < .001). Risk reduction was greater in specialist (HR = 0.03; 95% CI = 0.001‐0.13) compared to non‐specialist centres (HR = 0.11; 95% CI = 0.02‐0.37) (P = .07). In controls, 23.35 ovarian/peritoneal cancers were expected with 32 observed (HR = 1.37; 95% CI = 0.95‐1.91). RRBSO <35/<45 years reduces the risk of ovarian/peritoneal cancer by 95% in BRCA1/2 PVCs and may be greater in specialist centres.

A pre‐existing coordinated inflammatory microenvironment is associated with complete response of vulvar high‐grade squamous intraepithelial lesions to different forms of immunotherapy

AbstractImmunotherapy of vulvar high‐grade squamous intraepithelial lesion (vHSIL) is investigated as an alternative for surgery, because of high comorbidity and risk of recurrence. Limited evidence exists on the role and composition of the immune microenvironment in current immunotherapeutic approaches for vHSIL. The vHSIL of 29 patients biopsied before treatment with imiquimod were analyzed by two multiplex seven‐color immunofluorescence panels to investigate the pre‐existing T‐cell and myeloid cell composition in relation to treatment response. The samples were scanned with the Vectra multispectral imaging system. Cells were automatically phenotyped and counted with inForm advanced image analysis software. Cell counts and composition were compared to that of vHSIL patients before therapeutic vaccination (n = 29) and to healthy vulva (n = 27). Our data show that the immune microenvironment of complete responders (CR) to imiquimod resembled the coordinated infiltration with type 1 CD4+ and CD8+ T cells and CD14+ inflammatory myeloid cells also found in healthy vulva. However, more CD8+ T cells and FoxP3+ regulatory T cells were present in CR. The lesions of partial responders (PR) lacked such a coordinated response and displayed an impaired influx of CD14+ inflammatory myeloid cells. Importantly, complete responses after imiquimod or therapeutic vaccination showed the same dependency on a pre‐existing coordinated type 1 T‐cell and CD14+ myeloid cell infiltration. In conclusion, a good clinical outcome after two different forms of immunotherapy for vHSIL is associated with the presence of a primary inflammatory process resulting in the coordinated influx of several types of immune cells which is then amplified.

Serologic markers of Chlamydia trachomatis and other sexually transmitted infections and subsequent ovarian cancer risk: Results from the EPIC cohort

AbstractA substantial proportion of epithelial ovarian cancer (EOC) arises in the fallopian tube and other epithelia of the upper genital tract; these epithelia may incur damage and neoplastic transformation after sexually transmitted infections (STI) and pelvic inflammatory disease. We investigated the hypothesis that past STI infection, particularly Chlamydia trachomatis, is associated with higher EOC risk in a nested case‐control study within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort including 791 cases and 1669 matched controls. Serum antibodies against C. trachomatis, Mycoplasma genitalium, herpes simplex virus type 2 (HSV‐2) and human papillomavirus (HPV) 16, 18 and 45 were assessed using multiplex fluorescent bead‐based serology. Conditional logistic regression was used to estimate relative risks (RR) and 95% confidence intervals (CI) comparing women with positive vs. negative serology. A total of 40% of the study population was seropositive to at least one STI. Positive serology to C. trachomatis Pgp3 antibodies was not associated with EOC risk overall, but with higher risk of the mucinous histotype (RR = 2.30 [95% CI = 1.22‐4.32]). Positive serology for chlamydia heat shock protein 60 (cHSP60‐1) was associated with higher risk of EOC overall (1.36 [1.13‐1.64]) and with the serous subtype (1.44 [1.12‐1.85]). None of the other evaluated STIs were associated with EOC risk overall; however, HSV‐2 was associated with higher risk of endometrioid EOC (2.35 [1.24‐4.43]). The findings of our study suggest a potential role of C. trachomatis in the carcinogenesis of serous and mucinous EOC, while HSV‐2 might promote the development of endometrioid disease.

Metabolic factors contribute to T‐cell inhibition in the ovarian cancer ascites

Malignant ascites is one of the major clinical features of ovarian cancer, which serves as a carrier for the peritoneal dissemination of tumor cells and predicts a poor prognosis in patients. In the microenvironment of ovarian cancer ascites, antitumor immunity is suppressed, which enables the tumor cells to escape from immune surveillance. The metabolic factors, including hypoxia, nutrient deprivation and accumulation of metabolic products, contribute to the immunosuppressive status of malignant ascites. The malignant ascites and ovarian solid tumors exhibit differential metabolic profiles. In this review, we have summarized the most recent findings on the interaction between immune cells and metabolic factors in the ovarian cancer ascites. The effects of metabolic factors on the antitumor functions of T‐cells in the malignant ascites were analyzed. Finally, we have discussed the potential directions for future research in this field.

Ovarian cancer‐derived copy number alterations signatures are prognostic in chemoradiotherapy‐treated head and neck squamous cell carcinoma

DNA copy number alterations (CNAs) are frequent in cancer, and recently developed CNA signatures revealed their value in molecular tumor stratification for patient prognosis and platinum resistance prediction in ovarian cancer. Head and neck squamous cell carcinoma (HNSCC) is also characterized by high CNAs. In this study, we determined CNA in 173 human papilloma virus‐negative HNSCC from a Dutch multicenter cohort by low‐coverage whole genome sequencing and tested the prognostic value of seven cancer‐derived CNA signatures for these cisplatin‐ and radiotherapy‐treated patients. We find that a high CNA signature 1 (s1) score is associated with low values for all other signatures and better patient outcomes in the Dutch cohorts and The Cancer Genome Atlas HNSCC data set. High s5 and s7 scores are associated with increased distant metastasis rates and high s6 scores with poor overall survival. High cumulative cisplatin doses result in improved outcomes in chemoradiotherapy‐treated HNSCC patients. Here we find that tumors high in s1 or low in s6 are most responsive to a change in cisplatin dose. High s5 values, however, significantly increase the risk for metastasis in patients with low cumulative cisplatin doses. Together this suggests that the processes causing these CNA signatures affect cisplatin response in HNSCC. In conclusion, CNA signatures derived from a different cancer type were prognostic and associated with cisplatin response in HNSCC, suggesting they represent underlying molecular processes that define patient outcome.

High RIG‐I expression in ovarian cancer associates with an immune‐escape signature and poor clinical outcome

Ovarian cancer (OC) is the most lethal gynecological malignancy, with platinum‐based chemotherapy remaining the mainstay for adjuvant treatment after surgery. The lack of indication for immunotherapy may at least in part result from the lack of suitable biomarkers allowing stratification of potentially responding patients. In this monocentric study of 141 cases with OC, we used real‐time quantitative PCR to assess the expression of retinoic acid‐inducible gene‐I (RIG‐I) in primary tumor and healthy ovarian control tissues. RIG‐I expression was correlated to various clinicopathological characteristics as well as to a set of molecular and immunological markers. The prognostic significance of RIG‐I expression was queried in univariate and multivariate analyses and validated in an independent cohort. RIG‐I was overexpressed in the cancerous ovary and correlated with a higher tumor grade. The more aggressive Type‐II cancers and cancers with inactivating p53 mutations exhibited higher RIG‐I expression. RIG‐I levels were also elevated in cancers that recurred after remission or were platinum‐refractory. Survival analyses disclosed RIG‐I as an independent marker of poor outcome in OC. Continuative analyses revealed the molecular and immunological correlates of RIG‐I expression in the tumor microenvironment, including interferon production and a distinct immune‐regulatory signature involving checkpoint molecules (PD‐L1/PD‐1), the RNA‐editing enzyme ADAR1 and the regulatory T cell‐specific transcription factor FoxP3. We conclude that high RIG‐I expression associates with poor outcome in OC, which is explainable by local immunosuppression in the tumor bed. RIG‐I expression may inform checkpoint blockade and/or RIG‐I agonistic targeting in a subset of high‐risk OC patients.

High‐risk human papillomavirus distribution according to human immunodeficiency virus status among women with cervical cancer in Abidjan, Côte d'Ivoire, 2018 to 2020

AbstractAs human papillomavirus (HPV) immunisation and HPV‐based cervical cancer (CC) screening programmes expand across sub‐Saharan Africa, we investigated the potential impact of human immunodeficiency virus (HIV) status on high‐risk (HR)‐HPV distribution among women with CC in Côte d'Ivoire. From July 2018 to June 2020, paraffin‐embedded CC specimens diagnosed in Abidjan, Côte d'Ivoire were systematically collected and tested for HR‐HPV DNA. Type‐specific HR‐HPV prevalence was compared according to HIV status. Of the 170 CC specimens analysed (median age 52 years, interquartile range: [43.0‐60.0]), 43 (25.3%) were from women living with HIV (WLHIV) with a median CD4 count of 526 [373‐833] cells/mm3 and 86% were on antiretroviral therapy (ART). The overall HR‐HPV prevalence was 89.4% [95% CI: 84.7‐94.1]. All were single HR‐HPV infections with no differences according to HIV status (P = .8). Among HR‐HPV‐positive CC specimens, the most prevalent HR‐HPV types were HPV16 (57.2%), HPV18 (19.7%), HPV45 (8.6%) and HPV35 (4.6%), with no significant differences according to HIV status. Altogether, infection with HPV16/18 accounted for 71.1% [95% CI: 55.9‐86.2] of CC cases in WLHIV vs 78.9% [95% CI: 71.3‐86.5] in women without HIV (P = .3). The study confirms the major role of HPV16/18 in CC in Côte d'Ivoire and should support a regional scale‐up of HPV16/18 vaccination programmes regardless of HIV status. However, vaccines targeting additional HR‐HPV types, including HPV45 and HPV35, could further decrease future CC incidence in Côte d'Ivoire, both for WLHIV and women without HIV.

DNA methylation and copy number alterations in the progression of HPV‐associated high‐grade vulvar intraepithelial lesion

AbstractHuman papillomavirus (HPV)‐associated high‐grade vulvar intraepithelial lesion (HSIL) is a precursor of vulvar squamous cell carcinoma (VSCC). Because of the 8% cancer risk, many vulvar HSIL patients undergo aggressive and mutilating treatments. Characterizing HSIL by their progression risk can help individualize treatment strategies. Accordingly, copy number alterations (CNAs) and DNA methylation have been identified as biomarkers for cancer risk stratification of HSIL. Here, we assessed their potential correlation, and relation to HPV16 (sub)lineages and progression to vulvar cancer. Eighty‐two vulvar formalin‐fixed paraffin‐embedded (FFPE) samples, including controls, HSIL, HSIL adjacent to VSCC and VSCC, with previously determined DNA methylation profiles, were analysed for CNAs using mFAST‐SeqS. Genome‐wide z‐scores were calculated to determine overall aneuploidy (aneuploidy scores), and compared to the methylation levels and status of marker panel ZNF582/SST/miR124‐2. For 52 HPV16‐positive cases, HPV (sub)lineages were determined by Sanger sequencing. HPV16 lineage A was predominant (86.4%), followed equally by lineages B, C, and D. Frequent chromosomal alterations included chr1pq, chr3q, chr9q gains, and chr2q, chr4q losses. Median aneuploidy scores increased across disease categories, from 0 in controls, to 3 in HSIL, 16 in HSIL adjacent to VSCC and 29 in VSCC. A positive relationship between aneuploidy scores and DNA methylation levels was found (ρ = 0.61, Spearman's rank correlation test). Aneuploidy scores were significantly higher in methylation‐positive samples (p < .001). In conclusion, we showed that DNA methylation and CNAs both rise with increasing severity of disease, indicating their prognostic value for cancer risk stratification of HSIL, while no relation to HPV16 (sub)lineages was found.

p16/ki‐67 dual stain triage of individuals positive for HPV to detect cervical precancerous lesions

Abstractp16/Ki‐67 dual stain is a biomarker‐based test that can identify oncogenic transformation in cervical cells with higher sensitivity than cervical cytology, using the same samples taken for human papillomavirus (HPV) testing and liquid‐based cytology. Dual stain is approved by the US Food and Drug Administration (FDA) for triage of women with positive results by primary HPV testing or by HPV/cytology co‐testing and has recently been incorporated into management guidelines. In this review, we summarize the data showing the utility of dual stain in detecting precancers, reducing the number of unnecessary colposcopies, and reassuring women who test negative. We also discuss the implications of dual stain for future treatment practice and health economics.

Pubertal timing and incident uterine cancer in the Sister Study cohort

Abstract Younger age at menarche is an established uterine cancer risk factor. Age at onset of breast development (thelarche), the earliest marker of pubertal “unopposed” estrogen exposure, may also be relevant to uterine cancer risk, particularly considering rapid declines in age at thelarche over time in parallel with increasing uterine cancer incidence rates. Using data from 34,152 participants with an intact uterus when they enrolled in the US Sister Study cohort (2003–2009; ages 35–74 years), we examined associations of self‐reported ages at thelarche and menarche with incident uterine cancer using multivariable‐adjusted Cox proportional hazards regression. We stratified by birth cohort, race, weight relative to peers in childhood, and body mass index (BMI) at enrollment to explore potential effect measure modification and tested for statistical heterogeneity across strata. During follow‐up (median = 13.3 years), 445 women reported an incident uterine cancer diagnosis. Ages at thelarche (hazard ratio [HR] per 1‐year older: 0.91, 95% confidence interval [CI]: 0.85–0.97) and menarche (HR per 1‐year older: 0.90, 95% CI: 0.84–0.96) were inversely associated with uterine cancer incidence. Associations were similar in non‐Hispanic Black and White women and did not vary by relative childhood weight or BMI in adulthood. Inverse associations of thelarche and menarche were limited to women born in 1950 or later ( p ‐het <.05). These findings suggest that younger ages at thelarche and menarche, markers of earlier and potentially prolonged exposure to estrogen in the absence of progesterone during puberty, may enhance susceptibility to uterine carcinogenesis.

The role of cytokines in ovarian cancer drug resistance

Abstract Ovarian cancer is the leading cause of death among women diagnosed with female reproductive system cancers. While significant advances have been made in treating various types of cancer, progress in ovarian cancer treatment over the past 20 years has been minimal, and the treatment course of ovarian cancer is not linear. Although many patients initially respond to treatment and may experience tumor regression, 80% of patients relapse after one or multiple chemotherapy sessions. Cytokines play a crucial role in driving tumor progression, relapse, and drug resistance in ovarian cancer. The knowledge of ovarian cancer drug resistance and the function of cytokines in the development of tumor resistance is currently the subject of numerous relevant studies; meanwhile, the specific molecular pathways are being unearthed. Herein, we summarize the recent advancements in cytokine‐associated ovarian cancer drug resistance. In addition, we also present the cytokine targeting drugs in ameliorating ovarian cancer drug resistance. As multi‐effect factors, cytokines can induce multiple pathways to promote tumor progression and overcome extremely complex and heterogeneous living environments. From the perspective of various paths of cytokine function, the emergence of multi‐target drugs might be more promising for conquering ovarian cancer chemotherapy drug resistance.

Deciphering dual clinical entities associated with TP53 pathogenic variants: Insights from 53,085 HBOC panel analyses in French laboratories

AbstractTP53 is included in most cancer predisposition multigene panels, especially those exploring Hereditary Breast and Ovarian Cancer (HBOC) predisposition. The purpose of this study was to define the contribution of TP53 pathogenic variants (PV) to the HBOC phenotype by collecting genotypes and phenotypes of 398 patients harboring a TP53 variant identified by 53,085 HBOC panel sequencing in 15 French laboratories. Heterozygous TP53 variants were identified in 0.44% of HBOC panels, evenly distributed between PV and VUS. Breast cancers associated with TP53 were predominantly triple positive, particularly Her2+ breast cancer, in situ cancer, or phyllodes tumors (p < 0.0001 for both). Interestingly, TP53 PV were identified across all ages in breast cancer patients, with enrichment before 36y. We demonstrated that null variants were linked with the HBOC phenotype, and missense variants, especially with a dominant negative effect, with the LFS phenotype (p = 0.0096). Patients with breast cancer harboring null variants displayed an earlier age of onset compared to missense (p = 0.0030). Surprisingly, we identified, in late‐onset cancer patients, TP53 hotspot PV usually identified in classic LFS, which underlines variable penetrance. Thus, this study suggests the existence of two phenotypic entities associated with TP53 PV: clinical LFS and TP53‐related breast cancer. The type of TP53 variant, as well as modifying factors reflected in family history, may influence these phenotypes, and both should be considered to define the clinical follow‐up of patients and relatives.

Cervical cancer incidence in Denmark: Disentangling determinants of time trend

AbstractCervical cancer is a preventable disease. Nevertheless, stagnation has been seen in incidence rates also in countries with well‐functioning healthcare. On this basis, we investigated associations between control interventions and changes in cervical cancer incidence in Denmark from 2009 to 2022. Data on human papillomavirus (HPV)‐vaccination were retrieved from Staten's Serum Institute; on screening recommendations from Danish Health Authority, on screening performance from Danish Quality Database for Cervical Screening; and on cervical cancer incidence from Nordcan and Danish Cancer Register. We reported coverage with HPV vaccination (1+ dose); coverage with cervical cell samples; number of women with primary HPV tests; proportion of non‐normal cell samples without timely follow‐up; number of conizations; and cervical cancer incidence rates. In 2022, all women aged ≤29 had been offered childhood HPV vaccination with coverage of 80%–90%. By 2020–2022, the cervical cancer incidence rate in women aged 20–29 was 3 per 100,000; at level of disease elimination. In 2017, women aged 70+ were offered a one‐time HPV screening, and by 2020–2022, the old‐age peak in cervical cancer incidence had largely disappeared. From 2009 to 2022, proportion of non‐normal cell samples without timely follow‐up decreased from 20% to 10%, and conventional cytology was largely replaced by SurePath liquid‐based cytology; these factors could explain the steady decrease in cervical cancer incidence rate. Implementation of primary HPV screening in women aged 30–59 in 2021 was reflected in a, probably temporary, increase in the 2022 cervical cancer incidence rate. In conclusion, combined interventions with childhood HPV vaccination; one‐time HPV screening of elderly women; and better management of screening broke previous stagnation in cervical cancer incidence rate.

Field experience with the 8‐HPV‐type oncoprotein test for cervical cancer screening among HPV‐positive women living with and without HIV in LMICs

AbstractOverexpression of HPV‐oncoproteins E6 and E7 is necessary for HPV‐driven cervical carcinogenesis. Hence, these oncoproteins are promising disease‐specific biomarkers. We assessed the technical and operational characteristics of the 8‐HPV‐type OncoE6/E7 Cervical Test in different laboratories using cervical samples from HPV‐positive women living with (WLWH) and without HIV. The 8‐HPV‐type OncoE6/E7 Test (for short: “OncoE6/E7 test”) was performed in 2833 HIV‐negative women and 241 WLWH attending multicentric studies in Latin America (ESTAMPA study), and in Africa (CESTA study). Oncoprotein positivity were evaluated at each testing site, according to HIV status as well as type‐specific agreement with HPV‐DNA results. A feedback questionnaire was given to the operators performing the oncoprotein test to evaluate their impression and acceptability regarding the test. The OncoE6/E7 test revealed a high positivity rate heterogeneity across all testing sites (I2: 95.8%, p < .01) with significant lower positivity in WLWH compared to HIV‐negative women (12% vs 25%, p < .01). A similar HPV‐type distribution was found between HPV DNA genotyping and oncoprotein testing except for HPV31 and 33 (moderate agreement, k = 0.57). Twenty‐one laboratory technicians were trained on oncoprotein testing. Despite operators' concerns about the time‐consuming procedure and perceived need for moderate laboratory experience, they reported the OncoE6/E7 test as easy to perform and user‐friendly for deployment in resource‐limited settings. The high positivity rate variability found across studies and subjectivity in test outcome interpretation could potentially results in oncoprotein false positive/negative, and thus the need for further refinements before implementation of the oncoprotein testing in screen‐triage‐and‐treat approaches is warranted.

Long‐term prediction by DNA methylation of high‐grade cervical intraepithelial neoplasia: Results of the ARTISTIC cohort

AbstractMethylation markers have shown potential for triaging high‐risk HPV‐positive (hrHPV+) women to identify those at increased risk of invasive cervical cancer (ICC). Our aim was to assess the performance of the S5 DNA methylation classifier for predicting incident high‐grade cervical intraepithelial neoplasia (CIN) and ICC among hrHPV+ women in the ARTISTIC screening trial cohort. The S5 classifier, comprising target regions of tumour suppressor gene EPB41L3 and L1 and L2 regions of HPV16, HPV18, HPV31, and HPV33, was assayed by pyrosequencing in archived hrHPV+ liquid‐based samples from 343 women with high‐grade disease (139 CIN2, 186 CIN3, and 18 ICC) compared to 800 hrHPV+ controls. S5 DNA methylation correlated directly with increasing severity of disease and inversely with lead time to diagnosis. S5 could discriminate between hrHPV+ women who developed CIN3 or ICC and hrHPV+ controls (p <.0001) using samples taken on average 5 years before diagnosis. This relationship was independent of cytology at baseline. The S5 test showed much higher sensitivity than HPV16/18 genotyping for identifying prevalent CIN3 (93% vs. 61%, p = .01) but lower specificity (50% vs. 66%, p <.0001). The S5 classifier identified most women at high risk of developing precancer and missed very few prevalent advanced lesions thus appearing to be an objective test for triage of hrHPV+ women. The combination of methylation of host and HPV genes enables S5 to combine the predictive power of methylation with HPV genotyping to identify hrHPV‐positive women who are at highest risk of developing CIN3 and ICC in the future.

The risk of vaginal, vulvar and anal precancer and cancer according to high‐risk HPV status in cervical cytology samples

AbstractHigh‐risk human papillomavirus (hrHPV) is the cause of virtually all cervical cancers, most vaginal and anal cancers, and some vulvar cancer cases. With HPV testing becoming the primary screening method for cervical cancer, understanding the link between cervical hrHPV infection and the risk of other anogenital cancers is crucial. We assessed the risk of vulvar, vaginal and anal cancer and precancer (VIN2+, VaIN2+ and AIN2+) in a prospective cohort study including 455,349 women who underwent cervical hrHPV testing in Denmark from 2005 to 2020. We employed Cox proportional hazard models, adjusting for age, calendar year and HPV vaccination status, and estimated hazard ratios (HRs) and 95% confidence intervals (CI). We used the Aalen Johansen estimator to calculate the absolute risks of VIN2+, VaIN2+ and AIN2+. In total, 15% of the women were hrHPV positive at baseline. A positive cervical hrHPV test was associated with increased incidence of vulvar, vaginal and anal squamous cell carcinoma (SCC). Five‐year risk estimates of VIN2+, VaIN2+ and AIN2+ among hrHPV‐positive women (0.45%, 0.14% and 0.12%) were higher than among hrHPV‐negative women (0.14%, 0.01% and 0.05%). Particularly high risk was observed among the hrHPV‐positive women of the oldest age, with a history of anogenital precancer and those not HPV vaccinated. In conclusion, our study confirms the association between cervical hrHPV infection and non‐cervical anogenital precancers and cancers. Currently, no established risk threshold or guidelines for follow‐up. As HPV testing becomes the primary method for cervical cancer screening, future data will help define high‐risk groups and acceptable risk thresholds.

Efficacy and immunogenicity of AS04‐HPV‐16/18 vaccine in females with existing cervical HR‐HPV infection at first vaccination: A pooled analysis of four large clinical trials worldwide

AbstractFemales with existing high‐risk HPV (HR‐HPV) infections remain at risk of subsequent multiple or recurrent infections, on which benefit from HPV vaccines was under‐reported. We pooled individual‐level data from four large‐scale, RCTs of AS04‐HPV‐16/18 vaccine to evaluate efficacy and immunogenicity in females DNA‐positive to any HR‐HPV types at first vaccination. Females receiving the AS04‐HPV‐16/18 vaccine in the original RCTs constituted the vaccine group in the present study, while those unvaccinated served as the control group. Vaccine efficacy (VE) against new infections and associated cervical intraepithelial neoplasia (CIN) 2+ in females DNA‐negative to the considered HR‐HPV type but positive to any other HR‐HPV types, VE against reinfections in females DNA‐positive to the considered HR‐HPV type but cleared naturally during later follow‐up, and levels of anti‐HPV‐16/18 IgG were assessed. Our final analyses included 5137 females (vaccine group = 2532, control group = 2605). The median follow‐up time was 47.88 months (IQR: 45.72‐50.04). For the prevention of precancerous lesions related to the non‐infected HR‐HPV types at baseline, VE against HPV‐16/18 related CIN 2+ was 82.70% (95% CI: 63.70‐93.00%). For the prevention of reinfections related to the infected HR‐HPV types following natural clearance, VE against HPV‐16/18 12MPI was non‐significant (p > .05), albeit robust immunity persisted for at least 48 months. Females with existing HR‐HPV infections at first vaccination still benefit from vaccination in preventing precancers related to the non‐infected types at baseline. VE against reinfections related to the infected types following natural clearance remains to be further investigated.

Serum perfluorooctane sulfonate and perfluorooctanoate and risk of postmenopausal breast cancer according to hormone receptor status: An analysis in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial

Abstract Per‐ and polyfluoroalkyl substances (PFAS) are highly persistent endocrine‐disrupting chemicals that may contribute to breast cancer development; however, epidemiologic evidence is limited. We investigated associations between prediagnostic serum levels of perfluorooctane sulfonate (PFOS) and perfluorooctanoate (PFOA) and postmenopausal breast cancer risk, overall and by hormone receptor status, in a nested case‐control study of 621 cases and 621 matched controls in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. PFOS and PFOA levels were determined based on serum metabolomic profiling performed using ultraperformance liquid chromatography‐tandem mass spectrometry. We used multivariable conditional logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between each PFAS and breast cancer risk, overall, by estrogen receptor (ER) or progesterone receptor (PR) status, and by joint ER/PR status. We found little evidence of association between PFOS or PFOA and breast cancer risk overall. However, in subtype‐specific analyses, we observed statistically significant increased risks of ER+, PR+, and ER+/PR+ tumors for the third vs lowest quartile of serum PFOS (ORs [95% CIs] = 1.59 [1.01‐2.50], 2.34 [1.29‐4.23], and 2.19 [1.21‐3.98], respectively) and elevated but nonstatistically significant ORs for the fourth quartile. Conversely, for PFOA, modest positive associations with ER−, PR−, ER+/PR−, and ER−/PR− tumors were generally seen in the upper quartiles. Our findings contribute evidence supporting positive associations between serum PFOS and hormone receptor‐positive tumors, and possibly between PFOA and receptor‐negative tumors. Future prospective studies incorporating tumor hormone receptor status are needed to better understand the role of PFAS in breast cancer etiology.

Fragmentomics features of ovarian cancer

AbstractOvarian cancer (OC) is a major cause of cancer mortality in women worldwide. Due to the occult onset of OC, its nonspecific clinical symptoms in the early phase, and a lack of effective early diagnostic tools, most OC patients are diagnosed at an advanced stage. In this study, shallow whole‐genome sequencing was utilized to characterize fragmentomics features of circulating tumor DNA (ctDNA) in OC patients. By applying a machine learning model, multiclass fragmentomics data achieved a mean area under the curve (AUC) of 0.97 (95% CI 0.962–0.976) for diagnosing OC. OC scores derived from this model strongly correlated with the disease stage. Further comparative analysis of OC scores illustrated that the fragmentomics‐based technology provided additional clinical benefits over the traditional serum biomarkers cancer antigen 125 (CA125) and the Risk of Ovarian Malignancy Algorithm (ROMA) index. In conclusion, fragmentomics features in ctDNA are potential biomarkers for the accurate diagnosis of OC.

Recent trends in cervical cancer incidence, stage at diagnosis, and mortality according to county‐level income in the United States, 2000–2019

AbstractEarly evidence suggests that declining cervical cancer incidence reversed in low‐income regions in the United States in recent years; however, it is unclear whether there are distinct patterns by race/ethnicity and stage at diagnosis and if the increase has translated into rising mortality. Using Surveillance, Epidemiology, and End Results data, we evaluated trends in hysterectomy‐corrected cervical cancer incidence rates (2000–2019) and mortality rates (2005–2019) by county‐level income and race/ethnicity, with further stratification of incidence by stage at diagnosis. Following a period of decline, hysterectomy‐corrected cervical cancer incidence increased 1.0%/year (95% CI = 0.1% to 4.5%) among Non‐Hispanic White women in low‐income counties. Particularly, a statistically significant 4.4%/year (95% CI = 1.7% to 7.5%) increase in distant‐stage cancer occurred in this group. Additionally, recent increases in cervical cancer mortality (1.1%/year [95% CI = −1.4% to 3.7%]) were observed among this group and Non‐Hispanic Black women in low‐income counties (2.9%/year [95% CI = −2.3% to 18.2%]), but trends were not statistically significant. Among Hispanic women in low‐income counties, distant‐stage cervical cancer incidence increased 1.5%/year (95% CI = −0.6% to 4.1%), albeit not statistically significant. The increasing incidence of distant‐stage cervical cancer and mortality in specific racial/ethnic groups suggests that the recent introduction of higher sensitivity screening tests may not explain increasing trends in low‐income counties. Our findings suggest that the observed rise in cervical cancer incidence may reflect disruptions along the screening and treatment continuum. Future research to further comprehend these trends and continued enhancements in prevention are crucial to combat rising cervical cancer incidence and mortality in low‐income counties in the United States.

Outcome of early detection approach in control of breast, cervical, and oral cancer: Experience from a rural cancer center in India

AbstractIn low‐ and middle‐income countries most of the cancer patients attend the hospital at a late stage and treatment completion of these cases is challenging. The early detection program (EDP), in rural areas of Punjab state, India was initiated to identify breast, cervical, and oral cancer at an early stage by raising awareness and providing easy access to diagnosis and treatment. A total of 361 health education programs and 99 early detection clinics were organized. The symptomatic and self‐interested (non‐symptomatic individuals who opted for screening) cases visited the detection clinic. They were screened for breast, cervical, and/or oral cancer. Further diagnosis and treatment of screen‐positive cases were carried out at Homi Bhabha Cancer Hospital (HBCH), Sangrur. Community leaders and healthcare workers were involved in all the activities. The EDP, Sangrur removed barriers between cancer diagnosis and treatment with the help of project staff. From 2019 to 2023, a total of 221,317 populations were covered. Symptomatic and self‐interested individuals attended the breast (1627), cervical (1601), and oral (1111) examinations. 46 breast (in situ‐4.3%; localized‐52.2%), 9 cervical (localized‐77.8%), and 12 oral (localized‐66.7%) cancer cases were detected, and treatment completion was 82.6%, 77.8%, and 50.0%, respectively. We compared cancer staging and treatment completion of cases detected through EDP with the cases attended HBCH from Sangrur district in 2018; the difference between two groups is statistically significant. Due to the early detection approach, there is disease down‐staging and improvement in treatment completion. This approach is feasible and can be implemented to control these cancers in low‐ and middle‐income countries.

BRCA1 and BRCA2 germline testing in Cretan isolates reveals novel and strong founder effects

Germline BRCA1 and BRCA2 loss‐of‐function variants have been linked to increased breast and ovarian cancer risk, with more than 5,000 distinct pathogenic variants being reported worldwide. Among individuals of Greek descent, the BRCA1/2 variant spectrum is heterogeneous, but characterized by strong founder effects. As patients from certain geographical regions of Greece (like Crete) were underrepresented in previous studies, we hypothesized that isolated Cretans, a southern Greece islanders' population with distinct demographic, cultural and genetic features, could harbor founder BRCA1/2 mutations. A total of 304 breast or/and ovarian cancer patients of Cretan descent, fulfilling NCCN criteria for genetic testing, were tested by NGS or Sanger sequencing, followed by MLPA. Haplotype analysis was subsequently performed to investigate potential founder effects of recurrent alleles. Overall, 16.5% (50/304) of the tested patients carried 22 different pathogenic variants; 48% in BRCA1, 52% in BRCA2. Three variants, namely two in BRCA2 (Δexons 12 and 13 and c.7806‐2A>T) and one in BRCA1 (c.5492del), constituting approximately half (48%) of all detected pathogenic variants, were shown to have a founder effect, with all carriers sharing common haplotypes. Remarkably, these variants were confined to Cretans and have not been identified in other regions of Greece. The high prevalence of specific BRCA1/2 pathogenic variants among Cretans, provides the possibility of cost‐ and time‐efficient screening of the Cretan population. Integrating this knowledge in local public health services may have a significant impact on cancer prevention, and may serve as a starting point for the implementation of testing on a population level.

Comparative performance of the human papillomavirus test and cytology for primary screening for high‐grade cervical intraepithelial neoplasia at the population level

AbstractThe World Health Organization recommends high‐risk human papillomavirus (hrHPV)‐based screening for women 39 to 49 years, based on the greater accuracy of hrHPV‐based screening for cervical cancer detection. Many cervical cancer screening programs have incorporated hrHPV testing and multiple early cervical cancer detection strategies have been evaluated, mostly under controlled conditions. However, there are few evaluations of combined hrHPV and cytology strategies post‐implementation at the population level. Our study sought to estimate the relative yield of hrHPV testing compared to cervical cytology, as a primary screening test for cervical intraepithelial neoplasia grade 2+ (CIN2+), used at the population level. We analyzed screening data from Mexico's public cervical cancer prevention program from 2010 to 2015 in women 35 to 64 years. The study population consisted of two cohorts: one from a total of 2 881 962 cytology‐based screening tests and another from a total of 2 004 497 hrHPV‐based screening tests, which are concurrent in time. We performed a relative yield analysis using Poisson regression models to compare the effectiveness of hrHPV testing for CIN2+ with cervical cytology. A total of 4 886 459 records were analyzed, including 23 999 biopsies; 0.12% (n = 6166) had a CIN2+ histologic diagnosis. hrHPV testing with cytological triage detects twice as many CIN2+ cases as screening using cytology alone.

Performance of DNA methylation‐based biomarkers in the cervical cancer screening program of northern Portugal: A feasibility study

AbstractCervical cancer remains a health concern. Effective screening programs are critical to reduce the incidence and mortality. High‐risk HPV (hr‐HPV) testing as primary screening tool discloses high sensitivity but suboptimal specificity. Adequate triage tests to reduce unnecessary colposcopy referrals and overdiagnosis/overtreatment are crucial. Hence, we aimed to validate a panel of DNA methylation‐based markers as triage test for women hr‐HPV+ in the population‐based Regional Cervical Cancer Screening Program of Northern Portugal. Firstly, CADM1, MAL, FAM19A4 and hsa‐miR124‐2 promoter methylation levels were assessed by multiplex QMSP in a testing set of 402 FFPE tissue samples (159 normal samples and 243 cervical lesions, including 39 low‐grade intraepithelial squamous lesions [LSIL], 59 high‐grade intraepithelial squamous lesions [HSIL] and 145 cancerous lesions). Then, preliminary validation was performed in 125 hr‐HPV+ cervical scrapes (including 59 normal samples, 30 LSIL, 34 HSIL and 2 cancerous lesions). Higher MALme, FAM19A4me and hsa‐miR124‐2me methylation levels were disclosed in histological HSIL or worse (HSIL+) in testing set. Individually, markers depicted over 86% specificity for HSIL+ detection. In validation set, all these genes significantly differed between histological HSIL+ and low‐grade squamous intraepithelial lesions or less. In combination, these markers reached 74% specificity and 61% sensitivity for identification of histological HSIL+. We concluded that host gene methylation might constitute a useful referral triage tool of hr‐HPV+ women enrolled in the Cervical Cancer Screening Program of Northern Portugal.

Guideline‐concordant endometrial cancer treatment and survival in the Women's Health Initiative Life and Longevity After Cancer study

In the Women's Health Initiative (WHI) Life and Longevity After Cancer (LILAC) cohort, we examined predictors of guideline‐concordant treatment among endometrial cancer (EC) survivors and associations between receipt of guideline‐concordant treatment and survival. Receipt of guideline‐concordant EC treatment was defined according to year‐specific National Comprehensive Cancer Network (NCCN) guidelines. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for predictors of guideline‐concordant treatment receipt. We estimated multivariable‐adjusted hazard ratios (HRs) and 95% CIs for relationships between guideline‐concordant treatment and overall survival using Cox proportional hazards regression. We included 629 women with EC, of whom 83.6% (n = 526) received guideline‐concordant treatment. Receipt of guideline‐concordant treatment was less common among women with nonendometrioid histology (OR = 0.24, 95% CI = 0.13–0.45) but was more common among women living in the Midwest (OR = 2.09, 95% CI = 1.06–4.12) or West (OR = 3.02, 95% CI = 1.49–6.13) compared to the Northeast. In Cox regression models adjusted for age, histology and stage, receipt of guideline‐concordant EC treatment was borderline associated with improved overall survival (HR = 0.80, 95% CI = 0.60–1.01) in the overall population. Guideline‐concordant treatment was also linked with better overall survival among women with low‐grade uterine‐confined endometrioid EC or widely metastatic endometrioid EC. Guideline‐concordant treatment varies by some patient characteristics and those women in receipt of guideline‐concordant care had borderline improved survival. Studies evaluating regional differences in treatment along with randomized clinical trials to determine appropriate treatment regimens for women with aggressive tumor characteristics are warranted.

Cervical cancer in Mozambique: Clinical characteristics, treatment and survival of incident cases admitted to the Oncology Service of Maputo Central Hospital in 2016‐2018

AbstractIn Mozambique, cervical cancer is the most frequent cancer in women. However, studies about cervical cancer treatment and prognosis are scarce. We describe the clinical characteristics, treatment and survival of patients with cervical cancer admitted to Maputo Central Hospital (MCH) in 2016 to 2018. Sociodemographic, clinical and cancer‐related data were retrieved from clinical records of patients admitted to the Oncology Service of the MCH with an incident cervical cancer in 2016 to 2018 (n = 407). The Pathology Service database was used to obtain information regarding pathological diagnosis. Survival data was obtained through the MCH Cancer Registry and clinical records. Odds ratios for the association between patients' characteristics and the diagnosis of advanced stage cancer were computed using logistic regression. Survival analyses were performed using the Kaplan‐Meier estimator. A total of 91.2% of the patients were diagnosed with advanced disease (stage IIB‐IV) and squamous cell carcinoma was the predominant histological subtype. Most of the patients underwent chemotherapy (93.1%) but <7% were submitted to surgery, radiotherapy or brachytherapy. Those living with HIV had 3.4‐fold higher odds of advanced disease. Overall survival was 72.7% (95% confidence interval [CI]: 67.9‐77.0) at 1‐year and 51.0% (95%CI: 45.3‐56.3) at 2‐years. Those with early stage (IA‐IIA) and asymptomatic at diagnosis had a significantly higher 2‐year overall survival. In Mozambique, cervical cancer is diagnosed mostly in advanced stages, resulting in poor prognosis. This highlights the importance of HPV vaccination and screening, to decrease the burden of cervical cancer in this context.

Serum calretinin as an independent predictor for platinum resistance and prognosis in ovarian cancer

Calretinin (CRT) is a calcium‐binding protein that controls intracellular calcium signaling. Besides its prominent expression in neurons, serum CRT (sCRT) has recently been suggested as blood‐based biomarker for prediagnostic mesothelioma detection. CRT is expressed in ovarian cancer tissues in up to 40% of cases; however, its clinical relevance as blood‐based biomarker for ovarian cancer is unknown. sCRT was determined by calretinin enzyme‐linked immunoabsorbent assay (Calretinin‐ELISA, DLD Diagnostika GmbH, Hamburg, Germany) in a total of 515 serum samples from 116 healthy controls and 134 ovarian cancer patients (thereof 86% with Fédération Internationale de Gynécologie et d'Obstétrique [FIGO] III/IV), including samples at primary diagnosis and at four longitudinal follow‐up time points in the course of treatment and at recurrence. sCRT level was significantly increased in ovarian cancer patients compared to healthy controls (estimated difference = 0.3 ng/ml, p < 0.001), was mostly independent from CA125 (r ≤ 0.388) and enabled accurate discrimination between cases and controls (area under the curve = 0.85). Higher sCRT level at primary diagnosis predicted suboptimal debulking (p < 0.001) and was associated with advanced FIGO‐stage (p < 0.001) and increased amount of ascites (p < 0.001). sCRT levels at primary diagnosis and its dynamics in the course of chemotherapy were independent predictors for poor progression‐free survival (hazard ratio [HR] = 1.99, confidence interval [CI] = [1.13–3.52], p = 0.0181) and overall survival (HR = 15.4, CI = [1.92–124], p = 0.0099). Furthermore, sCRT at primary diagnosis or a relative sCRT increase in the time interval between surgery and the onset of chemotherapy were both independent predictors of platinum resistance (OR = 4.99, CI = [3.50–16,001], p = 0.0016; OR = 2.41, CI = [1.37–6,026], p = 0.0271, respectively). This is the first study that suggests sCRT as liquid biopsy marker for independent prediction of platinum resistance and prognosis.

Efficacy of thermal ablation for treatment of biopsy‐confirmed high‐grade cervical precancer among women living with HIV in Kenya

AbstractThe World Health Organization recommends thermal ablation (TA) as an alternative to cryotherapy within “screen‐and‐treat” cervical cancer programs in low‐ and middle‐income countries (LMICs), including among women living with HIV (WLWH). Data on TA efficacy among WLWH are limited, however. We conducted a clinical trial to evaluate efficacy of TA for treatment of biopsy‐confirmed cervical intraepithelial neoplasia grades 2 and 3 (CIN2/3) among WLWH in Kenya. Nonpregnant HPV‐positive WLWH age 25 to 65 years underwent colposcopy‐directed biopsy, and same‐day treatment with TA, if eligible. Women with biopsy‐confirmed CIN2/3 at baseline had colposcopy‐directed biopsies at 12 months to determine cure. A total of 376 participants underwent TA during the study period. At baseline, 238 (63.3%) had normal histology, 39 (10.4%) had CIN1, 15 (4.0%) had CIN2, 55 (14.6%) had CIN3, 7 (1.9%) had microinvasive cancer and 22 (5.6%) had indeterminate results. Twelve‐month follow‐up pathology results are available for 59 of 70 (84.3%) participants with CIN2/3 at baseline. Of these, 39 (66.1%, 95% CI 0.54‐0.99) had successful treatment, defined as biopsy‐confirmed CIN1 or normal findings, while 20 (33.9%, 95% CI 0.22‐0.46) had treatment failure, defined as persistent biopsy‐confirmed CIN2 or worse. Treatment failure was 23.1% (95% CI 0.17‐0.46) and 39.9% (95% CI 0.23‐0.51) among women with CIN2 and CIN3 at baseline, respectively. HIV‐positive women with CIN2/3 have high rates of treatment failure at 1‐year following thermal ablation. This highlights a significant limitation in the current WHO cervical cancer secondary‐prevention strategy and calls for strategies to optimize cervical precancer treatment in this population.

Gynaecologic and breast cancers in women living with HIV in South Africa: A record linkage study

AbstractBreast and gynaecologic cancers account for approximately half of all cancers diagnosed amongst women in South Africa, many of whom also live with HIV. We aimed to determine the incidence of and risk factors for developing breast and gynaecologic cancers in women living with HIV (WLHIV) in South Africa. This is a longitudinal analysis of the South African HIV Cancer Match study including women aged ≥15 years with two or more HIV‐related laboratory tests. We used Cox proportional hazard models to determine the association of Human Papilloma Virus (HPV)‐related and hormone‐related gynaecologic cancer with patient‐ and municipal‐level characteristics. From 3 447 908 women and 10.5 million years of follow‐up, we identified 11 384 incident and 7612 prevalent gynaecologic and breast cancers. The overall crude incidence rate was 108/1 00 000 person‐years (pyears) (95% confidence interval [CI]: 106‐110), with the highest incidence observed for cervical cancer (70/1 00 000 pyears; 95% CI: 68.5‐71.7). Low CD4 cell counts and high HIV RNA viral loads increased the risk of cervical and other HPV‐related cancers. Age was associated with both HPV‐related and hormone‐related cancers. Women accessing health facilities in high socioeconomic position (SEP) municipalities were more likely to be diagnosed with HPV‐related cancers and breast cancer than women accessing care in low SEP municipalities. It is important to improve the immunologic status of WLHIV as part of cancer prevention strategies in WLHIV. Cancer prevention and early detection programmes should be tailored to the needs of women ageing with HIV. In addition, SEP disparities in cancer diagnostic services have to be addressed.

Impact of the COVID‐19 pandemic on the hospital attendance of patients with primary cervical cancer in Heilongjiang, China

AbstractInformation regarding the impact of the coronavirus disease 2019 (COVID‐19) pandemic on cervical cancer in mainland China is lacking. We explored its impact on the hospital attendance of patients with primary cervical cancer. We included 1918 patients with primary cervical cancer who initially attended Harbin Medical University Cancer Hospital between January 23, 2019, and January 23, 2021. Attendance decreased by 31%, from 1135 in 2019 to 783 in 2020, mainly from January to June (𝜒2 = 73.362, P < .001). The percentage of patients detected by screening decreased from 12.1% in January‐June 2019 to 5.8% in January‐June 2020 (𝜒2 = 7.187, P = .007). Patients with stage I accounted for 28.4% in 2020 significantly lower than 36.6% in 2019 (𝜒2 = 14.085, P < .001), and patients with stage III accounted for 27.1% in 2020 significantly higher than 20.5% in 2019 (𝜒2 = 11.145, P < .001). Waiting time for treatment was extended from 8 days (median) in January‐June and July‐December 2019 to 16 days in January‐June (𝜒2 = 74.674, P < .001) and 12 days in July‐December 2020 (𝜒2 = 37.916, P < .001). Of the 179 patients who delayed treatment, 164 (91.6%) were for the reasons of the healthcare providers. Compared to 2019, the number of patients in Harbin or non‐Harbin in Heilongjiang Province and outside the province decreased, and cross‐regional medical treatment has been hindered. The COVID‐19 pandemic has negatively impacted cervical cancer patient attendance at the initial phase. These results are solid evidence that a strategy and mechanism for the effective attendance of cervical cancer patients in response to public health emergencies is urgently needed.

Parity is associated with better prognosis in ovarian germ cell tumors, but not in other ovarian cancer subtypes

AbstractOvarian cancer is influenced by reproductive factors, with a reduced risk of epithelial ovarian cancer in parous women. Nonepithelial ovarian cancer frequently affects young women and often precedes or occurs during the childbearing years. However, the impact of reproductive factors on ovarian cancer survival remains unclear: in epithelial ovarian cancer, data are conflicting, and subtype‐specific associations have not been examined, and in nonepithelial ovarian cancer, it has not been studied. Using Swedish registers, we evaluated associations between women's reproductive history and cancer‐specific mortality by subtype of epithelial and nonepithelial ovarian cancer in 3791 women born 1953 and later, diagnosed from 1990 to 2018. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were calculated using Cox‐proportional hazard models. Parity was associated with a 78% decreased risk of cause‐specific mortality in 243 women with germ cell tumors (GCTs) (parous vs nulliparous, adjusted for age at diagnosis: HR: 0.22 [95% CI 0.07‐0.62]), with a decreased risk with increasing number of births (per birth: HR: 0.60 [95% CI 0.38‐0.95]). We found no evidence of associations between parity and cause‐specific mortality among the 334 patients with sex‐cord stromal tumors, nor among the 3214 patients with epithelial ovarian cancer; neither overall, nor by subtype. In conclusion, in our large, population‐based study, parity was associated with a clearly better prognosis in GCTs but not in the other ovarian cancer subtypes. Future research on how hormone exposure impacts GCT development may lead to a better understanding of mechanisms affecting survival.

Exploiting epigenetic dependencies in ovarian cancer therapy

AbstractOvarian cancer therapy has remained fundamentally unchanged for 50 years, with surgery and chemotherapy still the frontline treatments. Typically asymptomatic until advanced stages, ovarian cancer is known as “the silent killer.” Consequently, it has one of the worst 5‐year survival rates, as low as 30%. The most frequent driver mutations are found in well‐defined tumor suppressors, such as p53 and BRCA1/2. In recent years, it has become clear that, like the majority of other cancers, many epigenetic regulators are altered in ovarian cancer, including EZH2, SMARCA2/4 and ARID1A. Disruption of epigenetic regulators often leads to loss of transcriptional control, aberrant cell fate trajectories and disruption of senescence, apoptotic and proliferation pathways. These mitotically inherited epigenetic alterations are particularly promising targets for therapy as they are largely reversible. Consequently, many drugs targeting chromatin modifiers and other epigenetic regulators are at various stages of clinical trials for other cancers. Understanding the mechanisms by which ovarian cancer‐specific epigenetic processes are disrupted in patients can allow for informed targeting of epigenetic pathways tailored for each patient. In recent years, there have been groundbreaking new advances in disease modeling through ovarian cancer organoids; these models, alongside single‐cell transcriptomic and epigenomic technologies, allow the elucidation of the epigenetic pathways deregulated in ovarian cancer. As a result, ovarian cancer therapy may finally be ready to advance to next‐generation treatments. Here, we review the major developments in ovarian cancer, including genetics, model systems and technologies available for their study and the implications of applying epigenetic therapies to ovarian cancer.

Risk of epithelial ovarian cancer Type I and II after hysterectomy, salpingectomy and tubal ligation—A nationwide case‐control study

AbstractThe proposed different origins and pathways to of the dualistic model of epithelial ovarian cancer (EOC) may affect and alter the potential risk reduction related to hysterectomy, salpingectomy and tubal ligation. The aim of our study was to analyze associations between hysterectomy, salpingectomy or tubal ligation and risk reduction of EOC Type I and II. In this nationwide register‐based case‐control study, women diagnosed with EOC, Fallopian tube or primary peritoneal cancer between 2008 and 2014 were included. Cases were classified into Type I and II according to histology and predefined criteria. The exposure variables: hysterectomy, salpingectomy and tubal ligation were identified from national registries. Conditional logistic regression analyses were performed to evaluate associations between Type I and II EOC and the exposure variables. Among 4669 registered cases, 4040 were eligible and assessed for subtyping resulting in 1033 Type I and 3007 Type II. Ten controls were randomly assigned to each case from the register of population. In regression analyses, women with previous salpingectomy had a significantly lower risk of EOC Type II (odds ratio [OR] 0.62; 95% confidence interval [95%CI] 0.45‐0.85) but not Type I (OR 1.16; 95%CI 0.75‐1.78). Hysterectomy was associated with a reduced risk of both EOC Type I (OR 0.71; 95%CI 0.52‐0.99) and Type II (OR 0.81; 95%CI 0.68‐0.96). Similar estimates were obtained for tubal ligation, although without statistical significance. The association between salpingectomy and reduced risk of EOC Type II supports the proposed theory of high‐grade serous cancer originating from the tubal fimbriae.

Human papillomavirus prevalence, genotype distribution, and prognostic factors of vaginal cancer

AbstractWe aimed to investigate human papillomavirus (HPV) prevalence and genotype distribution and prognostic factors in vaginal cancer (VC). VC patients who received treatment between 1989 and 2020 were retrospectively reviewed. L1 general polymerase chain reaction (PCR) followed by HPV Blot (King Car, I‐Lan, Taiwan) and E6 type‐specific‐PCR were performed for genotyping firstly. P16 and p53 immunohistochemistry staining was performed. Univariate and multivariate analyses identified predictors of clinical outcomes.79 VC patients were eligible for analysis. 73 patients (92.4%) were squamous cell carcinoma (SCC) and 6 (7.6%) as non‐SCC. The median follow‐up time was 134.3 months (range 0.9–273.4). Among nine initially HPV‐negative cases, seven were identified as being positive through HPV16/18/45/52/58 whole‐genome amplification followed by Sanger sequencing (WGASS). HPV DNA sequences were detected in 98.6% of SCC and 83.3% of non‐SCC, respectively, with HPV16 (49.4%), HPV52 (15.2%) and HPV58 (8.9%) being predominant. Patients with paraaortic lymph node (LN) metastasis had a 5‐year cancer‐specific survival (CSS) rate of 0%. Multivariate analysis revealed that only p16 and stage were significantly correlated with prognosis. Variables with strong correlations (p16‐ and HPV‐positivity, LN metastasis and stage), were included in models 2–5 alternatively. Stage III/IV (hazard ratio [HR] = 3.64–4.56) and LN metastasis (HR = 2.81–3.44) were significant negative predictors of CSS, whereas p16‐positivity (HR = 0.29–0.32) and HPV‐positivity (HR = 0.14) were related to better prognosis. In conclusion, 97.5% of VCs were HPV‐positive with WGASS. Stage III/IV and LN metastasis were significant negative predictors, whereas p16‐ and HPV‐positivity were significantly associated with better prognosis.

Immune‐Hot tumor features associated with recurrence in early‐stage ovarian clear cell carcinoma

AbstractOvarian clear cell carcinoma (OCCC) is a distinct histotype of ovarian cancer, which usually presages a worse prognosis upon recurrence. Identifying patients at risk for relapse is an unmet need to improve outcomes. A retrospective cohort analysis of 195 early‐stage OCCC patients diagnosed between January 2011 and December 2019 at National Taiwan University Hospital was conducted to identify prognostic factors for recurrence, progression‐free survival (PFS) and overall survival (OS). Molecular profiling of tumors was performed in a case‐controlled cohort matched for adjuvant therapy for biomarker discovery. Multivariate Cox proportional hazard model revealed that paclitaxel‐based chemotherapy was associated with better PFS than nonpaclitaxel chemotherapy (HR = 0.19, P = .006). The addition of bevacizumab was associated with better PFS, compared to no bevacizumab (HR = 0.09, P = .02). Neither showed significant improvement in OS. Recurrence is associated with an Immune‐Hot tumor feature (P = .03), the CTLA‐4‐high subtype (P = .01) and increased infiltration of immune cells in general. The Immune‐Hot feature (HR = 3.39, P = .005) and the CTLA‐4‐high subtype (HR = 2.13, P = .059) were associated with worse PFS. Immune‐Hot tumor features could prognosticate recurrence in early‐stage OCCC.

Modelling the impact of prevention strategies on cervical cancer incidence in South Africa

AbstractIn 2020, the World Health Organisation (WHO) published a strategy to eliminate cervical cancer as a public health concern. In South Africa, despite having a national screening policy in place since 2000, diagnosed cervical cancer incidence has shown no signs of decline. We extend a previously developed individual‐based model for human immunodeficiency virus (HIV) and human papillomavirus (HPV) infection to include progression to cervical cancer. The model accounts for future reductions in HIV incidence and prevalence and includes a detailed cervical cancer screening algorithm, based on individual‐level data from the public health sector. We estimate the impact of the current prevention programme and alternative screening scenarios on cervical cancer incidence. The South African screening programme prevented 8600 (95%CI 4700‐12 300) cervical cancer cases between 2000 and 2019. At current levels of prevention (status quo vaccination, screening, and treatment), age‐standardised cervical cancer incidence will reduce from 49.4 per 100 000 women (95%CI 36.6‐67.2) in 2020, to 12.0 per 100 000 women (95%CI 8.0‐17.2) in 2120. Reaching WHO's prevention targets by 2030 could help South Africa reach elimination (at the 10/100 000 threshold) by 2077 (94% probability of elimination by 2120). Using new screening technologies could reduce incidence to 4.7 per 100 000 women (95%CI 2.8‐6.7) in 2120 (44% probability of elimination at the 4/100 000 threshold). HPV vaccination and decreasing HIV prevalence will substantially reduce cervical cancer incidence in the long term, but improvements to South Africa's current screening strategy will be required to prevent cases in the short term. Switching to new screening technologies will have the greatest impact.

Umbilical metastases: Real‐world data shows abysmal outcome

AbstractUmbilical metastases form a clinical challenge, especially when they represent the first sign of malignant disease and the primary tumor is unknown. Our study aims to generate insight into the origin and timing of umbilical metastasis, as well as patient survival, using population‐based data. A nationwide review of pathology records of patients diagnosed with an umbilical metastasis between 1979 and 2015 was performed. Data was collected from the Nationwide Network and Registry of Histopathology and Cytopathology (PALGA) and the Netherlands Cancer Registry. Kaplan‐Meier analyses and log‐rank testing were used to estimate overall survival and a Cox proportional hazard model was used to determine multivariable hazard ratios. A total of 806 patients with an umbilical metastasis were included. There were 210 male (26.1%) and 596 female (73.9%) patients. Distribution of umbilical metastases was different between male and female patients due to the high incidence of umbilical metastases originating from the ovaries in females. They most frequently originated from the ovaries in female patients (38.8%) and from the colon in male patients (43.8%). In 18% of cases no primary tumor could be identified. Prognosis after diagnosis of an umbilical metastasis was dismal with a median survival of 7.9 months (95% confidence interval 6.7‐9.1). The origin of the primary tumor was an independent prognostic factor for overall survival. In conclusion, umbilical metastases relatively rare, mainly originating from intraabdominal primary tumors. Survival is dependent on the origin of the primary tumor and poor overall survival rates warrant early recognition.

Tumor‐associated macrophage‐targeted therapeutics in ovarian cancer

AbstractOvarian cancer is one of the most common gynecological malignancies. The tumor microenvironment plays an important role in regulating the progression of ovarian cancer. Macrophages, which are important immune cells in the tumor microenvironment, participate in the regulation of various biological behaviors and influence the prognosis of ovarian cancer. A large number of studies have targeted macrophages for the treatment of ovarian cancer. In addition, macrophages also play a regulatory role by interacting with other immune cells, including T cells and mesothelial cells, in the ovarian cancer microenvironment. In this review, we discuss the progress made in macrophage‐targeted therapy for ovarian cancer. Although there are still several challenges in using this treatment, targeted macrophage therapy is still a promising treatment for ovarian cancer.

Statin use and survival following a diagnosis of ovarian cancer: A prospective observational study

AbstractMost women with ovarian cancer have a poor prognosis, but studies have reported an association between statin use and improved survival. We investigated the potential survival benefit of statins in women with ovarian cancer using data from the Ovarian cancer Prognosis and Lifestyle study, a prospective study of Australian women aged 18 to 79 years, diagnosed with ovarian cancer from 2012 to 2015 and followed for 5 to 8 years. We obtained information from patient‐completed questionnaires and medical records. We defined exposure based on prediagnosis use, as most women used statins continuously (prediagnosis and postdiagnosis) and few started using statins postdiagnosis. We measured survival from date of first treatment (surgery or neoadjuvant chemotherapy) until date of death or last follow‐up. We used Cox regression to calculate hazard ratios (HR) and 95% confidence intervals (CI), adjusting for potential confounders. To reduce bias due to confounding by indication, we also applied inverse probability of treatment weighting (IPTW). Of 955 eligible women, 21% reported statin use before diagnosis. Statin users had a slightly better survival (HR = 0.90, 95% CI = 0.70‐1.15) that was driven by lipophilic statin use (HR = 0.82, 95% CI = 0.61‐1.11), with no association for hydrophilic statins (HR = 1.04, 95% CI = 0.72‐1.49). The IPTW model weighted to all women with ovarian cancer also suggested a possible reduction in mortality associated with lipophilic statins (HR = 0.80, 95% CI = 0.54‐1.21). In analyses restricted to women with hyperlipidaemia, the HRs were further from the null. Our findings are consistent with previous evidence, suggesting that lipophilic statins might improve ovarian cancer survival. Further investigation, in larger cohorts, or preferably in a randomised trial, is required.

Frequency and molecular characteristics of PALB2‐associated cancers in Russian patients

AbstractPALB2 is а high‐penetrance gene for hereditary breast cancer (BC). Our study aimed to investigate the spectrum of PALB2 mutations in Russian cancer patients. PALB2 sequencing revealed pathogenic variants in 3/190 (1.6%) young‐onset and/or familial and/or bilateral BC cases but none in 96 ovarian cancer (OC) or 172 pancreatic cancer patients. Subsequently, seven recurrent PALB2 pathogenic alleles were selected from this and previous Slavic studies and tested in an extended patient series. PALB2 pathogenic variants were detected in 5/585 (0.9%) “high‐risk” BC, 10/1508 (0.7%) consecutive BC and 5/1802 (0.3%) OC cases. Haplotyping suggested that subjects with Slavic alleles c.509‐510delGA (n = 10) and c.172‐175delTTGT (n = 4) as well as carriers of Finnish c.1592delT mutation (n = 4) originated from a single founder each, while PALB2 p.R414X allele (n = 4) had at least two independent founders. Somatic loss of heterozygosity (LOH) was revealed in 5/10 chemonaive BCs and in 0/2 BC samples obtained after neoadjuvant therapy. Multigene sequencing identified somatic PALB2 inactivating point mutation in one out of two tumors without PALB2 LOH but in none of four BCs with PALB2 LOH. Genomic instability, as determined by NGS, was observed in four out of five tumors with biallelic PALB2 inactivation but not in the BC sample with the preserved wild‐type PALB2 allele. PALB2 germ‐line mutations contribute to a small fraction of cancer cases in Russia. The majority although not all PALB2‐driven BCs have somatic inactivation of the remaining PALB2 allele and therefore potential sensitivity to platinum compounds and PARP inhibitors.

Evaluating the role of alcohol consumption in breast and ovarian cancer susceptibility using population‐based cohort studies and two‐sample Mendelian randomization analyses

AbstractAlcohol consumption is correlated positively with risk for breast cancer in observational studies, but observational studies are subject to reverse causation and confounding. The association with epithelial ovarian cancer (EOC) is unclear. We performed both observational Cox regression and two‐sample Mendelian randomization (MR) analyses using data from various European cohort studies (observational) and publicly available cancer consortia (MR). These estimates were compared to World Cancer Research Fund (WCRF) findings. In our observational analyses, the multivariable‐adjusted hazard ratios (HR) for a one standard drink/day increase was 1.06 (95% confidence interval [CI]; 1.04, 1.08) for breast cancer and 1.00 (0.92, 1.08) for EOC, both of which were consistent with previous WCRF findings. MR ORs per genetically predicted one standard drink/day increase estimated via 34 SNPs using MR‐PRESSO were 1.00 (0.93, 1.08) for breast cancer and 0.95 (0.85, 1.06) for EOC. Stratification by EOC subtype or estrogen receptor status in breast cancers made no meaningful difference to the results. For breast cancer, the CIs for the genetically derived estimates include the point‐estimate from observational studies so are not inconsistent with a small increase in risk. Our data provide additional evidence that alcohol intake is unlikely to have anything other than a very small effect on risk of EOC.

miR‐181a overexpression predicts the poor treatment response and early‐progression of serous ovarian cancer patients

AbstractOvarian cancer (OC) remains a leading cause of gynecological cancer‐related death worldwide, characterized by poor 5‐year survival. Molecular markers could serve as crucial tools of personalized prognosis and therapy. Herein, we present miR‐181a as novel predictor of OC prognosis, using five independent OC cohorts. In particular, a screening (n = 81) and an institutionally independent validation (n = 100, OVCAD multicenter study) serous OC (SOC) cohorts were analyzed. Bagnoli et al (2016) OC179 (n = 124) to OC133 (n = 100) and TCGA (n = 489) served as external validation cohorts. Patients’ survival and disease progression were assessed as clinical endpoint events. Bootstrap analysis was performed for internal validation and decision curve analysis was utilized to evaluate clinical benefit. miR‐181a overexpression was unveiled as powerful and independent molecular predictor of patients’ poor survival and higher risk for disease progression after debulking surgery and platinum‐based chemotherapy. Analysis of the OVCAD institutionally independent cohort, as well as of Bagnoli et al. and TCGA external cohorts further confirmed the unfavorable prognostic nature of miR‐181a overexpression in SOC. Strikingly, multivariate prognostic models incorporating miR‐181a with established disease markers clearly improved patients’ risk‐stratification and offered superior clinical benefit in OC prognostication. Conclusively, miR‐181a evaluation could augment prognostic accuracy and support precision medicine decisions in OC.

Ethnic‐specificity, evolution origin and deleteriousness of Asian BRCA variation revealed by over 7500 BRCA variants derived from Asian population

AbstractPathogenic variation in BRCA1 and BRCA2 (BRCA) causes high risk of breast and ovarian cancer, and BRCA variation data are important markers for BRCA‐related clinical cancer applications. However, comprehensive BRCA variation data are lacking from the Asian population despite its large population size, heterogenous genetic background and diversified living environment across the Asia continent. We performed a systematic study on BRCA variation in Asian population including extensive data mining, standardization, annotation and characterization. We identified 7587 BRCA variants from 685 592 Asian individuals in 40 Asia countries and regions, including 1762 clinically actionable pathogenic variants and 4915 functionally unknown variants (https://genemutation.fhs.um.edu.mo/Asian-BRCA/). We observed the highly ethnic‐specific nature of Asian BRCA variants between Asian and non‐Asian populations and within Asian populations, highlighting that the current European descendant population‐based BRCA data is inadequate to reflect BRCA variation in the Asian population. We also provided archeological evidence for the evolutionary origin and arising time of Asian BRCA variation. We further provided structural‐based evidence for the deleterious variants enriched within the functionally unknown Asian BRCA variants. The data from our study provide a current view of BRCA variation in the Asian population and a rich resource to guide clinical applications of BRCA‐related cancer for the Asian population.

Trends in the incidence of ovarian cancer in sub‐Saharan Africa

AbstractOvarian cancer (OC) is one of the commonest cancers of women in sub‐Saharan Africa (SSA), although to date no data have been available on time trends in incidence to better understand the disease pattern in the region. We estimate time trends by histological subtype from 12 population‐based cancer registries in 11 countries: Kenya (Nairobi), Mauritius, Seychelles, Uganda (Kampala), Congo (Brazzaville), Zimbabwe (Bulawayo and Harare), Cote d'Ivoire (Abidjan), The Gambia, Mali (Bamako), Nigeria (Ibadan) and South Africa (Eastern Cape). The selected registries were those that could provide consistent estimates of the incidence of ovarian cancer and with quality assessment for periods of 10 or more years. A total of 5423 cases of OC were included. Incidence rates have been increasing in all registries except Brazzaville, Congo, where a nonsignificant decline of 1% per year was seen. Statistically significant average annual increases were seen in Mauritius (2.5%), Bamako (5.3%), Ibadan (3.9%) and Eastern Cape (8%). Epithelial ovarian cancer was responsible for the increases observed in all registries. Statistically significant average annual percentage changes (AAPC) for epithelial OC were present in Bamako (AAPC = 5.9%), Ibadan (AAPC = 4.7%) and Eastern Cape (AAPC = 11.0%). Creating awareness among professionals of the growing importance of the disease is surely an important step to improving availability of, and access to, diagnosis and treatment of OC in SSA. Support must be given to the cancer registries to improve the availability of good‐quality data on this important cancer.

Infertility and ovarian cancer risk: Evidence from nine prospective cohort studies

AbstractEpidemiological studies have investigated the relationship between infertility and the risk of ovarian cancer (OC); however, the results have been inconsistent. We therefore conducted the first meta‐analysis to update and quantify the aforementioned association based on prospective cohort studies. Studies were identified by searching PubMed, EMBASE and Web of Science databases up to January 8, 2020. We extracted data from the studies and performed quality assessments. Summary relative risks (RRs) with 95% confidence intervals (CIs) were calculated using a random‐effects model. Publication bias, and subgroup, meta‐regression and sensitivity analyses were also conducted. Nine prospective cohort studies with a total of 10 383 OC cases and 6 278 830 participants were included in the present study. The summary RR of the association between infertility and the risk of OC was 1.51 (95% CI: 1.35‐1.69), with low heterogeneity. Positive associations were observed in most subgroup analyses stratified by predefined factors, including region, duration of follow‐up, study quality, causes of infertility, invasiveness of OC, infertility treatment status and adjustment of potential confounding parameters. No significant publication bias was detected. Our findings suggest that infertility in women were associated with an increased risk of OC.

Detection of aberrant methylation of HOXA9 and HIC1 through multiplex MethyLight assay in serum DNA for the early detection of epithelial ovarian cancer

Accumulated evidence revealed that aberrant CpG island hypermethylation plays an important role in carcinogenesis which can serve as a promising target for molecular detection in body fluids. Despite a myriad of attempts to diagnose ovarian cancer (OC) at an early stage, this clinical aim remains a major challenge. To date, no single biomarker is able to accurately detect early OC in either tissue or body fluid. Aberrant DNA methylation patterns in circulating DNA provide highly specific cancer signals. In our study, we establish a novel panel of methylation‐specific genes for the development of a TaqMan based qPCR assay to quantify methylation levels. We analyzed promoter methylation of homeobox A9 (HOXA9) and hypermethylated in cancer 1 (HIC1) quantitatively in 120 tissue samples and in 70 matched serum cell‐free DNA (CFDNA) of cancerous and noncancerous samples by MethyLight assay. HOXA9 and HIC1 methylation occurred in 82.3 and 80.0% of OC tissue samples in singleplex assay, thereby confirming that methylation was highly cancer‐specific. When either or both gene promoter showed methylation, the sensitivity was 88.2% with a specificity of 88.6% in tissue samples. The combined sensitivity for this novel marker panel in serum CFDNA was 88.9% (area under the curve [AUC] = 0.95). In contrast, no hypermethylation was observed in serum from matched cancer‐free control women. Our results confirm the elevated performance of novel epigenetic marker panel (HOXA9 and HIC1) when analyzed in tissue and matched serum samples. Our findings reveal the potential of this biomarker panel as a suitable diagnostic serum biomarker for early screening of OC.

Expression profiles of PRKG1, SDF2L1 and PPP1R12A are predictive and prognostic factors for therapy response and survival in high‐grade serous ovarian cancer

High‐grade serous ovarian cancer (HGS‐EOCs) is generally sensitive to front‐line platinum (Pt)‐based chemotherapy although most patients at an advanced stage relapse with progressive resistant disease. Clinical or molecular data to identify primary resistant cases at diagnosis are not yet available. HGS‐EOC biopsies from 105 Pt‐sensitive (Pt‐s) and 89 Pt‐resistant (Pt‐r) patients were retrospectively selected from two independent tumor tissue collections. Pathway analysis was done integrating miRNA and mRNA expression profiles. Signatures were further validated in silico on a cohort of 838 HGS‐EOC cases from a published dataset. In all, 131 mRNAs and 5 miRNAs belonging to different functionally related molecular pathways distinguish Pt‐s from Pt‐r cases. Then, 17 out of 23 selected elements were validated by orthogonal approaches (SI signature). As resistance to Pt is associated with a short progression‐free survival (PFS) and overall survival (OS), the prognostic role of the SI signature was assessed, and 14 genes associated with PFS and OS, in multivariate analyses (SII signature). The prognostic value of the SII signature was validated in a third extensive cohort. The expression profiles of SDF2L1, PPP1R12A and PRKG1 genes (SIII signature) served as independent prognostic biomarkers of Pt‐response and survival. The study identified a prognostic molecular signature based on the combined expression profile of three genes which had never been associated with the clinical outcome of HGS‐EOC. This may lead to early identification, at the time of diagnosis, of patients who would not greatly benefit from standard chemotherapy and are thus eligible for novel investigational approaches.

Pro‐tumoral behavior of omental adipocyte‐derived fibroblasts in tumor microenvironment at the metastatic site of ovarian cancer

AbstractAdipocyte‐rich omentum offers “good soil” for disseminating ovarian cancer (OvCa), contributing to therapeutic difficulty. However, little is understood about the association between adipocytes and tumor growth at peritoneal dissemination site. Herein, we report the induction of adipocyte dedifferentiation by OvCa cells and pro‐tumorigenic effects of resulted adipocyte‐derived fibroblasts. We confirmed that malignant ascites promoted the dedifferentiation of the primary human adipocytes obtained from surgical omental specimen into omental adipocyte‐derived fibroblast (O‐ADF) that possess both mesenchymal stem cell and myofibroblast‐like features. This promotion of dedifferentiation by malignant ascites was blocked by addition of Wnt signaling inhibitor. The effects of dedifferentiated adipocytes in proliferation and migration of OvCa cells were analyzed with in vitro coculturing experimental models and in vivo mice model, and we demonstrated that OvCa cell lines showed enhanced proliferative characteristics, as well as increased migratory abilities upon coculturing with O‐ADF. Additionally, exogenous transforming growth factor‐β1 augmented desmoplastic morphological change of O‐ADF, leading to higher proliferative ability. Our results suggest that OvCa cells promote dedifferentiation of peritoneal adipocytes by activating Wnt/β‐catenin signaling, and generated O‐ADFs exhibit pro‐tumoral hallmarks.

Therapeutic targeting of soluble CD146/MCAM with the M2J‐1 monoclonal antibody prevents metastasis development and procoagulant activity in CD146‐positive invasive tumors

Initially discovered in human melanoma, CD146/MCAM is expressed on many tumors and is correlated with cancer progression and metastasis. However, targeting CD146 remains challenging since it is also expressed on other cell types, as vessel cells, where it displays important physiological functions. We previously demonstrated that CD146 is shed as a soluble form (sCD146) that vectorizes the effects of membrane CD146 on tumor angiogenesis, growth and survival. We thus generated a novel monoclonal antibody, the M2J‐1 mAb, which specifically targets sCD146, but not membrane CD146, and counteracts these effects. In our study, we analyzed the effects of sCD146 on the dissemination and the associated procoagulant phenotype in two highly invasive human CD146‐positive cancer cell lines (ovarian and melanoma). Results show that sCD146 induced epithelial to mesenchymal transition, favored the generation of cancer stem cells and increased the membrane expression of tissue factor. Treatment of cancer cells with sCD146 in two experimental models (subcutaneous xenografting and intracardiac injection of cancer cells in nude mice) led to increased tumor dissemination and procoagulant activity. The M2J‐1 mAb drastically reduced metastasis but also procoagulant activity, in particular by decreasing the number of circulating tumor microparticles, and blocked the relevant signaling pathways as demonstrated by RNA expression profiling experiments. Thus, our findings demonstrate that sCD146 mediates important pro‐metastatic and procoagulant effects in two CD146‐positive tumors. Targeting sCD146 with the newly generated M2J‐1 mAb could constitute an innovative strategy for preventing dissemination and thromboembolism in many CD146‐positive tumors.

Risk of specific types of ovarian cancer after borderline ovarian tumors in Denmark: A nationwide study

Population‐based evidence regarding risk of ovarian cancer after a borderline ovarian tumor (BOT) is sparse. We aimed to examine the incidence of specific types of ovarian cancer in women with serous or mucinous BOTs in a nationwide cohort study with up to 36 years of follow‐up. Using the nationwide Danish Pathology Data Bank, we identified 4,281 women with a BOT (2,058 serous BOTs and 2,223 mucinous BOTs) in Denmark during 1978–2012. We computed standardized incidence ratios (SIRs) to compare the incidence of ovarian cancer among women with BOTs compared to general population rates. We found that a serous BOT was especially and strongly associated with subsequent serous ovarian cancer (SIR = 9.2; 95% CI: 6.8–12.2), and that a mucinous BOT was strongly related to mucinous ovarian cancer (SIR = 18.6; 95% CI: 10.8–29.8). The SIRs remained elevated ≥10 years after a serous BOT and up to 5–9 years after a mucinous BOT. The increased incidence of serous ovarian cancer in women with a serous BOT was mostly pronounced in women <50 years at the serous BOT diagnosis. In conclusion, women with a serous BOT experience long‐term increased incidence of serous ovarian cancer, and women with a mucinous BOT have long‐term elevated incidence of mucinous ovarian cancer compared to the general population. This is the first population‐based study to show compelling evidence of the histo‐specific increased risk of ovarian cancer following specific types of BOTs. Thus, these results are supportive of the hypothesis that BOTs may be precursor lesions to carcinomas of the corresponding histologic type.

Novel ovarian cancer maintenance therapy targeted at mortalin and mutant p53

Current ovarian cancer maintenance therapy is limited by toxicity and no proven impact on overall survival. To study a maintenance strategy targeted at missense mutant p53, we hypothesized that the release of mutant p53 from mortalin inhibition by the SHetA2 drug combined with reactivation of mutant p53 with the PRIMA‐1MET drug inhibits growth and tumor establishment synergistically in a mutant‐p53 dependent manner. The Cancer Genome Atlas (TCGA) data and serous ovarian tumors were evaluated for TP53 and HSPA9/mortalin status. SHetA2 and PRIMA‐1MET were tested in ovarian cancer cell lines and fallopian tube secretory epithelial cells using isobolograms, fluorescent cytometry, Western blots and ELISAs. Drugs were administered to mice after peritoneal injection of MESOV mutant p53 ovarian cancer cells and prior to tumor establishment, which was evaluated by logistic regression. Fifty‐eight percent of TP53 mutations were missense and there were no mortalin mutations in TCGA high‐grade serous ovarian cancers. Mortalin levels were sequentially increased in serous benign, borderline and carcinoma tumors. SHetA2 caused p53 nuclear and mitochondrial accumulation in cancer, but not in healthy, cells. Endogenous or exogenous mutant p53 increased SHetA2 resistance. PRIMA‐1MET decreased this resistance and interacted synergistically with SHetA2 in mutant and wild type p53‐expressing cell lines in association with elevated reactive oxygen species/ATP ratios. Tumor‐free rates in animals were 0% (controls), 25% (PRIMA1MET), 42% (SHetA2) and 67% (combination). SHetA2 (p = 0.004) and PRIMA1MET (p = 0.048) functioned additively in preventing tumor development with no observed toxicity. These results justify the development of SHetA2 and PRIMA‐1MET alone and in combination for ovarian cancer maintenance therapy.

Association of genomic variants at the human leukocyte antigen locus with cervical cancer risk, HPV status and gene expression levels

AbstractThe human leukocyte antigen (HLA) locus on chromosome 6 has been reported to be associated with cervical cancer. We investigated two independent single‐nucleotide polymorphisms in a large case‐control series of cervical dysplasia and carcinoma that has been newly established by the German Cervigen Consortium, comprising a total of 2481 cases and 1556 healthy females. We find significant associations for both variants, rs9272117 at HLA‐DQA1 and rs2844511 at MICA and HCP5, with cervical disease. Both variants showed evidence of association with invasive cervical cancer (rs9272117: OR 0.89, 95% CI 0.79‐0.99, P = .036; rs2844511: OR 1.17, 95% CI 1.04‐1.31, P = .008) and with high‐grade dysplasia (rs9272117: OR 0.78, 95% CI 0.70‐0.87, P = 7.1 × 10−6; rs2844511: OR 1.13, 95% CI 1.01‐1.26, P = .035), as well as in a combined analysis of both groups (rs9272117: OR 0.83, 95% CI 0.75‐0.91, P = 6.9 × 10−5; rs2844511: OR 1.14, 95% CI 1.04‐1.26, P = .005). Variant rs2844511, but not rs9272117, also showed modest evidence of association with low‐grade dysplasia (OR 1.26, 95% CI 1.04‐1.54, P = .019). In case‐only analyses, rs2844511 tended to predict HPV status (P = .044) and rs9272117 tended to associate with HPV16 (P = .022). RNA studies in cervical samples showed a significant correlation in the transcript levels of MICA, HCP5 and HLA‐DQA1, suggesting extensive co‐regulation. All three genes were upregulated in HPV16‐positive samples. In stratified analyses, rs9272117 was associated with HLA‐DQA1 levels, specifically in HPV‐positive samples, while rs2844511 was associated with MICA and HCP5 levels. The risk allele of rs2844511 was required for correlations between MICA or HCP5 with HLA‐DQA1. Altogether, our results support 6p21.32‐33 as the first consistent cervical cancer susceptibility locus and provide evidence for a link between genetic risk variants, HPV16 status and transcript levels of HLA‐DQA1, HCP5 and MICA, which may contribute to tumor immune evasion.

Pregnancy duration and ovarian cancer risk: A 50‐year nationwide cohort study

AbstractA woman's reproductive history is strongly associated with her risk of ovarian cancer. However, it is unclear how pregnancies of different duration impact a woman's ovarian cancer risk, and therefore, what part of a pregnancy explains the protective effect. Using a cohort of all Danish women followed from 1968 to 2018, with prospectively registered information on reproductive history (eg, gestational duration of pregnancies, tubal ligation and resection and hormonal pharmaceutical use), we investigated the effect of pregnancy duration on ovarian cancer risk. We adjusted for potential confounders, such as age at pregnancy and time since pregnancy, using log‐linear Poisson regression to isolate the effect of pregnancy duration on ovarian cancer risk. Among 2.5 million Danish women with 4.4 million pregnancies, a pregnancy was associated with a reduction of ovarian cancer risk of 21% (95% CI, 14%‐28%), 26% (95% CI, 21%‐31%), 12% (95% CI, 7%‐17%) and 3% (95% CI, −5% to 11%) compared to one less, for the first, second, third and fourth pregnancy, respectively (P < .001 for heterogeneity), with similar effects of induced abortions, spontaneous abortions and childbirths. Sensitivity analysis of age at pregnancy, time since pregnancy and other potential confounders did not change these findings. The reduced ovarian cancer risk associated with pregnancy is primarily driven by the first three pregnancies, with similar effects of induced abortion, spontaneous abortions and childbirth, suggesting that mainly exposure to early pregnancy factors, and not pregnancy duration, protect against ovarian cancer.

Hematological disorders after salvage PARPi treatment for ovarian cancer: Cytogenetic and molecular defects and clinical outcomes

AbstractInhibitors of poly(ADP‐ribose) polymerase (PARPi) are increasingly employed as salvage therapy in epithelial ovarian cancer (EOC), but cytotoxic drug exposure along with PARP inhibition may favor development of hematological disorders. In our study, of 182 women with EOC treated with PARPi, 16 (8.7%) developed therapy‐related myeloid neoplasms (t‐MNs), with 12 cases of myelodysplasia and 4 of acute myeloid leukemia. All experienced persistent cytopenia after PARPi discontinuation. Seven patients had del(5q)/−5 and/or del(7q)/−7, nine had a complex karyotype and TP53 mutations, recently reported as risk factor for t‐MNs in EOC post‐PARPi, were found in 12 out of 13 tested patients. Four patients had a rapid and fatal outcome, one had stable disease, eleven underwent induction therapy, followed by allogeneic hematopoietic cell transplantation in seven. Three of these 11 patients experienced refractory disease, and 8 had complete remission. During a 6.8 months (range 2.3‐49) median observation time, 3 out of 16 patients were alive, with one surviving patient free of both solid and hematological tumors. Ten patients died because of leukemia, two because of transplant‐related events, one from heart failure. Five more patients experienced persistent cell blood count abnormalities following PARPi discontinuation, without reaching MDS diagnostic criteria. A customized Myelo‐panel showed clonal hematopoiesis in all five patients. These findings confirm the actual risk of t‐MNs in EOC patients after chemotherapy and prolonged PARPi therapy. The management of these patients is complex and outcomes are extremely poor. Careful diagnostic procedures are strongly recommended whenever unusual cytopenias develop in patients receiving PARPi therapy.

Type‐ and age‐specific natural history of high‐risk human papillomavirus infections in healthy women: A prospective cohort study in China

Abstract As cervical cancer screening shifts from cytology to HPV testing, clarifying the type‐ and age‐specific natural history of HR‐HPV is crucial, especially in regions with bimodal prevalence patterns where longitudinal data remain limited. We analyzed baseline HR‐HPV‐positive participants from the control arm of a bivalent HPV‐16/18 vaccine trial in China, with follow‐up over 5.5 years. Cox regression and competing risk models were applied to evaluate the progression, clearance, and persistence of these HR‐HPV infections. Among 534 HR‐HPV‐positive women at baseline, 98 CIN2+ lesions were identified (52 at baseline, 46 during follow‐up). HPV‐16 and HPV‐31 exhibited the highest immediate CIN2+ risk (21.1%), followed by HPV‐33 (17.1%) and HPV‐58 (12.7%). When stratified by baseline cytology, the LSIL+ group showed the highest immediate risk of CIN2+ (29.5% among the HR‐HPV‐positive participants), followed by the ASC‐US (10.5%). In the longitudinal analysis, competing risk models revealed significant type‐specific differences in progression (Gray's test P  = 0.0158) and clearance (Gray's test P  <0.0001). HPV‐16, ‐31, ‐18, and ‐58 showed relatively high progression (27.1%, 19.2%, 16.1%, and 11.2%) and low clearance (72.9%, 69.2%, 83.9%, and 88.8%). CIN2+ risk was strongly genotype‐dependent; beyond HPV‐16/18, types ‐31, ‐33, and ‐58 also warrant particular attention in screening and clinical management. Additionally, although a slightly higher CIN2+ progression risk was observed in younger women compared to older women, the difference was not statistically significant (Gray's test P =  0.4389), indicating the need for confirmation in larger studies. These findings enhance the understanding of the natural history of type‐specific HR‐HPV and age‐specific progression in initially screen‐positive populations.

Ovarian cancer today and tomorrow: A global assessment by world region and Human Development Index using GLOBOCAN 2020

AbstractOvarian cancer remains to have relatively poor prognosis particularly in low‐resourced settings. It is therefore important to continually examine the burden of ovarian cancer to identify areas of disparities. Our study aims to provide an overview of the global burden of ovarian cancer using the GLOBOCAN 2020 estimates by country, world region, and Human Development Index (HDI) levels, as well as the predicted future burden by the year 2040 by HDI. Age‐standardized incidence and mortality rates for ovarian cancer in 185 countries were calculated by country, world region, and for the four‐tier HDI. The number of new cases and deaths were projected for the year 2040 based on demographic projections by HDI category. Approximately 314 000 new ovarian cancer cases and 207 000 deaths occurred in 2020. There were marked geographic variations in incidence rates, with the highest rates observed in European countries with very high HDI and low rates were found in African countries within the lowest HDI group. Comparable mortality rates were observed across the four‐tier HDI. Relative to 2020 estimates, our projection for 2040 indicates approximately 96% and 100% increase in new ovarian cancer cases and deaths, respectively, among low HDI countries compared to 19% and 28% in very high HDI countries. Our study highlights the disproportionate current and future burden of ovarian cancer in countries with lower HDI levels, calling for global action to reduce the burden and inequality of ovarian cancer in access to quality cancer care and treatment.

Chasing the origin of 23 recurrent BRCA1 mutations in Pakistani breast and ovarian cancer patients

AbstractKnowledge of population specific BRCA1/2 founder mutations provides a valuable and cost‐effective genetic testing strategy. Twenty‐three recurrent BRCA1 mutations have been identified previously in 100 Pakistani breast and/or ovarian cancer families. These accounted for 72.5% of all BRCA1 mutations identified. In our study, we investigated whether these mutations (identified in ≥2 unrelated patients) have a common ancestral origin and estimated the ages of these mutations. Haplotype analyses were performed in 188 individuals (100 index patients, 88 relatives) from Pakistani breast/ovarian cancer families, all harboring one of the 23 recurrent BRCA1 mutations, and 90 healthy controls. Six microsatellite markers (D17S800, D17S1801, D17S855, D17S1322, D17S1323, and D17S951) were analyzed. Mutation ages were estimated using DMLE+2.3 software. An identical haplotype of different length was found in families harboring the same BRCA1 mutation and suggested founder effects for all 23 mutations. Sixteen founder mutations were ethnicity‐specific: 15 occurred in families of Punjabi background and one in a family of Pathan background. The remaining seven mutations occurred in families with two ethnic backgrounds. All BRCA1 founder mutations were estimated to have arisen approximately 147 to 159 generations ago. Our findings suggest founder effects for all 23 recurrent BRCA1 mutations. This knowledge allows the design and development of a cost effective local genetic testing strategy in Pakistan.

Integrated molecular profiling of patient‐derived ovarian cancer models identifies clinically relevant signatures and tumor vulnerabilities

AbstractHigh‐grade serous ovarian carcinoma (HGSOC) is a highly aggressive and intractable neoplasm, mainly because of its rapid dissemination into the abdominal cavity, a process that is favored by tumor‐associated peritoneal ascites. The precise molecular alterations involved in HGSOC onset and progression remain largely unknown due to the high biological and genetic heterogeneity of this tumor. We established a set of different tumor samples (termed the As11‐set) derived from a single HGSOC patient, consisting of peritoneal ascites, primary tumor cells, ovarian cancer stem cells (OCSC) and serially propagated tumor xenografts. The As11‐set was subjected to an integrated RNA‐seq and DNA‐seq analysis which unveiled molecular alterations that marked the different types of samples. Our profiling strategy yielded a panel of signatures relevant in HGSOC and in OCSC biology. When such signatures were used to interrogate the TCGA dataset from HGSOC patients, they exhibited prognostic and predictive power. The molecular alterations also identified potential vulnerabilities associated with OCSC, which were then tested functionally in stemness‐related assays. As a proof of concept, we defined PI3K signaling as a novel druggable target in OCSC.

The relative risk of noncervical high‐risk human papillomavirus‐related (pre)malignancies after recurrent cervical intraepithelial neoplasia grade 3: A population‐based study

Women with cervical intraepithelial neoplasia grade 3 (CIN3) have a long‐lasting increased risk for noncervical high‐risk human papillomavirus (hrHPV)‐related (pre)malignancies. The aim of our study was to estimate this risk in women with recurrent CIN3 compared to women without a history of CIN3 and women with a single episode of CIN3. Women with a CIN3 diagnosis between 1990 and 2010 were obtained from the Dutch Pathology Registry (PALGA) and matched with a control group of women without CIN3. Analysis has been conducted in a subset of women with recurrent CIN3, defined as reoccurrence minimally 2 years post‐treatment. Cases of noncervical hrHPV‐related (pre)malignancies of the anus, vulva, vagina and oropharynx were identified until 2015 and incidence rate ratios (IRRs) were estimated. Then, 1,797 women with recurrent CIN3 were included with a median age of 34 years (range 18–76) and 31,594 person‐years of follow‐up. Women with recurrent CIN3 had an increased risk of developing noncervical hrHPV‐related (pre)malignancies compared to women without CIN3 with an IRR of 25.96 (95%CI 6.32–106.58). The IRR was 2.48 (95% CI 1.87–3.30) compared to women with a single episode of CIN3. Studies on posttreatment follow‐up and prophylactic hrHPV vaccination are warranted.

Human papillomavirus genotypes in cervical and other HPV‐related anogenital cancer in Rwanda, according to HIV status

The study aim was to describe human papillomavirus (HPV)‐attributable cancer burden in Rwanda, according to anogenital cancer site, HPV type, age and HIV status. Tissue specimens of cervical, vulvar, vaginal, penile and anal cancer diagnosed in 2012–2018 were retrieved from three cancer referral hospitals and tested for high‐risk (HR) HPV DNA. Cervical cancer represented the majority of cases (598 of 738), of which 96.0% were HR‐HPV positive. HPV‐attributable fractions in other cancer sites varied from 53.1% in 81 penile, through 76.7% in 30 vulvar, 83.3% in 24 vaginal, up to 100% in 5 anal cases. HPV16 was the predominant HR‐HPV type in cervical cancer (55.0%), followed by HPV18 (16.6%) and HPV45 (13.4%). HPV16 also predominated in other cancer sites (60–80% of HR‐HPV‐attributable fraction). For cervical cancer, type‐specific prevalence varied significantly by histology (higher alpha‐9 type prevalence in 509 squamous cell carcinoma vs. higher alpha‐7 type prevalence in 80 adenocarcinoma), but not between 501 HIV‐negative and 97 HIV‐positive cases. With respect to types targeted, and/or cross‐protected, by HPV vaccines, HPV16/18 accounted for 73%, HPV31/33/45/52/58 for an additional 22% and other HR‐HPV types for 5%, of HPV‐attributable cancer burden, with no significant difference by HIV status nor age. These data highlight the preventive potential of the ongoing national HPV vaccination program in Rwanda, and in sub‐Saharan Africa as a whole. Importantly for this region, the impact of HIV on the distribution of causal HPV types was relatively minor, confirming type‐specific relevance of HPV vaccines, irrespective of HIV status.

Attendance at early recall and colposcopy in routine cervical screening with human papillomavirus testing

AbstractAttendance at early recall and colposcopy is crucial to attaining the benefits of primary high‐risk human papillomavirus (HR‐HPV)‐based screening. Within the English HPV pilot, we analysed deprivation‐ and age‐related patterns of attendance at colposcopy and 12‐ and 24‐month early recall of HR‐HPV positive women screened in 2013 to 2015 (N = 36 466). We fitted logistic regression models for adjusted odds ratios (OR). Despite high overall attendance, area deprivation had a small but significant impact at both early recalls, for example, attendance at 24 months was 86.3% and 83.0% in less vs more deprived areas, respectively (ORadj: 0.76; 95% CI: 0.67‐0.87). Older women (≥30 years) were more likely to attend early recall than younger women (<30 years), for example, attendance at 24 months was 86.1% vs 82.3%, respectively (ORadj: 1.32, 95% CI: 1.16‐1.51). Most women attended colposcopy following a baseline referral, with 96.9% attendance among more deprived and 97.8% among less deprived areas (ORadj: 0.70; 95% CI: 0.55‐0.88). Differences in colposcopy attendance by deprivation level at 12 and 24 months were of approximately the same magnitude. In conclusion, attendance at early recall and colposcopy was reassuringly high. Although there were statistically significant differences by deprivation and age group, these were small in absolute terms.

Effective methylation triage of HPV positive women with abnormal cytology in a middle‐income country

AbstractThe S5‐methylation test, an alternative to cytology and HPV16/18 genotyping to triage high‐risk HPV‐positive (hrHPV+) women, has not been widely validated in low‐middle‐income countries (LMICs). We compared S5 to HPV16/18 and cytology to detect cervical intraepithelial neoplasia Grade 2 or worse (CIN2+) and CIN3+ in hrHPV+ women selected from a randomized pragmatic trial of 2661 Colombian women with an earlier‐borderline abnormal cytology. We included all hrHPV+ CIN2 and CIN3+ cases (n = 183) age matched to 183 <CIN2 hrHPV+. Baseline specimens were HPV‐genotyped and tested by S5‐methylation, blinded to cytology, histology and initial HPV results. We evaluated the test performance of predefined S5‐classifier (cut‐point 0.8) and a post hoc classifier at a different cut‐point (3.1). S5 sensitivity for CIN2+ was 82% (95% confidence interval [CI] 76.4‐87.5) and for CIN3+ 77.08% (95% CI 65.19‐88.97). S5 sensitivity was higher than HPV16/18 sensitivity (48.1%, 95% CI 40.85‐55.33) or cytology (31.21%, 95% CI 24.50‐37.93) but with lower specificity (35%, 95% CI 28.1‐42). At cut‐point 3.1, S5 sensitivity for CIN2+ (55.2%, 95% CI 48‐62.4) or CIN3+ (64.6%, 95% CI 51.0‐78.1) was also superior to HPV16/18 (P < .05) or cytology (P < .0001). At this cut‐point S5 specificity (76%, 95% CI 69.8‐82.1 for <CIN2) was higher than HPV16/18 (67.21%, 95% CI 60.41‐74.01, P = .0062) and similar to cytology (75.57%, 95% CI 69.34‐81.79, P = 1). HPV16/18 plus cytology sensitivity was similar to S5 for CIN3+, however, false‐positive rate was higher (50.27% vs. 24.04%). High sensitivity is crucial in LMICs, S5‐methylation exceeded HPV16/18 or cytology sensitivity with comparable specificity for CIN2+ and CIN3+ in hrHPV‐positive Colombian women. Furthermore, S5 triage had comparable sensitivity and significantly fewer false positives than cytology and HPV16/18 combination.

Methylation markers FAM19A4 and miR124‐2 as triage strategy for primary human papillomavirus screen positive women: A large European multicenter study

AbstractIn human papillomavirus (HPV) cervical cancer screening, cytology is used as triage to counter the low specificity of HPV testing. VALID‐SCREEN is a EU‐multicenter, retrospective study conducted to evaluate the clinical performance of the FAM19A4/miR124‐2 methylation‐based molecular triage test as a substitute or addition to cytology as reflex testing of HPV screen positive women. FAM19A4/miR124‐2 methylation test (QIAsure Methylation Test) was evaluated in 2384 HPV‐positive cervical screening samples, from women 29‐76 years of age, derived from four EU countries. Specimens were collected in ThinPrep or SurePath media, HPV‐status, concurrent cytology, and histology diagnosis were provided by the parent institutes. The control population consisted of women with no evidence of disease within 2 years of follow‐up. A total of 899 histologies were retrieved; 527 showed no disease, 124 CIN2 (5.2%), 228 CIN3 (9.6%) and 20 cervical cancers (0.8%); 19 of 20 screen‐detected cervical cancers were found methylation‐positive (sensitivity 95%). Overall specificity of FAM19A4/miR124‐2 methylation test was 78.3% (n = 2013; 95%CI: 76‐80). The negative predictive value of hrHPV positive, methylation‐negative outcomes were 99.9% for cervical cancer (N = 1694; 95%CI: 99.6‐99.99), 96.9% for ≥CIN3 (95%CI: 96‐98), and 93.0% for ≥CIN2 (95%CI: 92‐94). Overall sensitivity for CIN3 using FAM19A4/miR124‐2 methylation test was 77% (n = 228; 95%CI: 71‐82). CIN3 sensitivity was uniform between centers independent of sample collection medias, DNA extraction methods and HPV screening tests. Being objectively reported compared to the subjectivity of cytology, equally performing across settings and screening methods, the FAM19A4/miR124‐2 methylation constitute an alternative/supplement to cytology as triage method to be investigated in real‐life pilot implementation.

Role of human papillomavirus status after conization for high‐grade cervical intraepithelial neoplasia

AbstractHuman papillomavirus (HPV) is the well‐established etiologic factor for cervical neoplasia. Cervical conization constitutes an effective treatment for high‐grade cervical intraepithelial neoplasia (HG‐CIN). We conducted an observational study for long‐term outcomes and HPV genotype changes after conization for HG‐CIN. Between 2008 and 2014, patients with newly diagnosed HG‐CIN before conization (surveillance new [SN] group) and those who had undergone conization without hysterectomy (surveillance previous [SP] group) were enrolled. HPV testing and Pap smear were performed periodically for the SN and SP (collectively S) groups. All other patients receiving conization for HG‐CIN during the study period were identified from our hospital database. Those eligible but not enrolled into our study were assigned to the non‐surveillance (non‐S) group. For the S group (n = 493), the median follow‐up period was 74.3 months. Eighty‐four cases had recurrent CIN Grade 2 or worse (CIN2+) (5‐year cumulative rate: 14.8%), of which six had invasive cancer. Among the 84 patients, 65 (77.4%) exhibited type‐specific persistence in the paired HPV results, whereas only 7 (8.3%) harbored new HPV types that belonged to the 9‐valent vaccine types. Among the 7397 non‐S patients, 789 demonstrated recurrent CIN2+, of which 57 had invasive cancer. The stages distribution of those progressed to invasive cancer in the non‐S group were more advanced than the S group (P = .033). Active surveillance might reduce the severity of those progressed to cancer. Because a majority of the patients with recurrent CIN2+ had persistent type‐specific HPV infections, effective therapeutic vaccines are an unmet medical need.

Choosing the optimal HPV vaccine: The health impact and economic value of the nonavalent and bivalent HPV vaccines in 48 Gavi‐eligible countries

AbstractThe human papillomavirus (HPV) vaccines may provide some level of cross‐protection against high‐risk HPV genotypes not directly targeted by the vaccines. We evaluated the long‐term health and economic impacts of routine HPV vaccination using either the nonavalent HPV vaccine or the bivalent HPV vaccine in the context of 48 Gavi‐eligible countries. We used a multi‐modeling approach to compare the bivalent with or without cross‐protection and the nonavalent HPV vaccine. The optimal, that is, most cost‐effective, vaccine was the vaccine with an incremental cost‐effectiveness ratio below the per‐capita gross domestic product (GDP) for each country. By 2100 and assuming 70% HPV vaccination coverage, a bivalent vaccine without cross‐protection, a bivalent vaccine with favorable cross‐protection and the nonavalent vaccine were projected to avert 14.9, 17.2 and 18.5 million cumulative cases of cervical cancer across all 48 Gavi‐eligible countries, respectively. The relative value of the bivalent vaccine compared to the nonavalent vaccine increased assuming a bivalent vaccine conferred high cross‐protection. For example, assuming a cost‐effectiveness threshold of per‐capita GDP, the nonavalent vaccine was optimal in 83% (n = 40) of countries if the bivalent vaccine did not confer cross‐protection; however, the proportion of countries decreased to 63% (n = 30) if the bivalent vaccine conferred high cross‐protection. For lower cost‐effectiveness thresholds, the bivalent vaccine was optimal in a greater proportion of countries, under both cross‐protection assumptions. Although the nonavalent vaccine is projected to avert more cases of cervical cancer, the bivalent vaccine with favorable cross‐protection can prevent a considerable number of cases and would be considered a high‐value vaccine for many Gavi‐eligible countries.

The European response to the WHO call to eliminate cervical cancer as a public health problem

AbstractThe age‐standardised incidence of cervical cancer in Europe varies widely by country (between 3 and 25/100000 women‐years) in 2018. Human papillomavirus (HPV) vaccine coverage is low in countries with the highest incidence and screening performance is heterogeneous among European countries. A broad group of delegates of scientific professional societies and cancer organisations endorse the principles of the WHO call to eliminate cervical cancer as a public health problem, also in Europe. All European nations should, by 2030, reach at least 90% HPV vaccine coverage among girls by the age of 15 years and also boys, if cost‐effective; they should introduce organised population‐based HPV‐based screening and achieve 70% of screening coverage in the target age group, providing also HPV testing on self‐samples for nonscreened or underscreened women; and to manage 90% of screen‐positive women. To guide member states, a group of scientific professional societies and cancer organisations engage to assist in the rollout of a series of concerted evidence‐based actions. European health authorities are requested to mandate a group of experts to develop the third edition of European Guidelines for Quality Assurance of Cervical Cancer prevention based on integrated HPV vaccination and screening and to monitor the progress towards the elimination goal. The occurrence of the COVID‐19 pandemic, having interrupted prevention activities temporarily, should not deviate stakeholders from this ambition. In the immediate postepidemic phase, health professionals should focus on high‐risk women and adhere to cost‐effective policies including self‐sampling.

Defining benchmarks for tolerable risk thresholds in cancer screening: Impact of HPV vaccination on the future of cervical cancer screening

AbstractThe performance of cervical cancer screening will decline as a function of lower disease prevalence—a consequence of successful human papillomavirus (HPV) vaccination. Replacement of cytology with molecular HPV testing as the primary screening test and adoption of risk‐based screening, with less intense screening of vaccinated individuals and initiated at older ages is expected to improve efficiency. However, policy officials may decide to further reduce or eliminate screening as the ratio of benefits to harms continues to decline. To evaluate the level of risk currently tolerated for different cancers in the United States (ie, for which clinical guidelines do not recommend secondary prevention though effective screening methods exist), we used US cancer registry data to compare incidence (2008‐2012) and survival (1988‐2011) associated with different cancers for which organized screening is recommended and not recommended. The most common cancer at ages 70 to 74 years (ie, age group with highest cancer incidence and reasonable life expectancy to consider screening in the US) satisfying Wilson and Jungner's classic screening criteria was vulvar cancer (incidence = 9/100 000 females). In comparison, the incidence of cervical cancer among females 65 years of age (the upper recommended age limit for screening) was 13 cases per 100 000 females (low as a reflection of effective screening), whereas 10‐year survival was 66% (similar to vulvar cancer at 67%). Our approach of defining tolerable risk in cancer screening could help guide future decisions to modify cervical screening programs.

FAM19A4/miR124‐2 methylation in invasive cervical cancer: A retrospective cross‐sectional worldwide study

Widespread adoption of primary human papillomavirus (HPV)‐based screening has encouraged the search for a triage test which retains high sensitivity for the detection of cervical cancer and precancer, but increases specificity to avoid overtreatment. Methylation analysis of FAM19A4 and miR124‐2 genes has shown promise for the triage of high‐risk (hr) HPV‐positive women. In our study, we assessed the consistency of FAM19A4/miR124‐2 methylation analysis in the detection of cervical cancer in a series of 519 invasive cervical carcinomas (n = 314 cervical scrapes, n = 205 tissue specimens) from over 25 countries, using a quantitative methylation‐specific PCR (qMSP)‐based assay (QIAsure Methylation Test®). Positivity rates stratified per histotype, FIGO stage, hrHPV status, hrHPV genotype, sample type and geographical region were calculated. In total, 510 of the 519 cervical carcinomas (98.3%; 95% CI: 96.7–99.2) tested FAM19A4/miR124‐2 methylation‐positive. Test positivity was consistent across the different subgroups based on cervical cancer histotype, FIGO stage, hrHPV status, hrHPV genotype, sample type and geographical region. In conclusion, FAM19A4/miR124‐2 methylation analysis detects nearly all cervical carcinomas, including rare histotypes and hrHPV‐negative carcinomas. These results indicate that a negative FAM19A4/miR124‐2 methylation assay result is likely to rule out the presence of cervical cancer.

Impact of screening on cervical cancer incidence: A population‐based case–control study in the United States

Cervical cancer is widely preventable through screening, but little is known about the duration of protection offered by a negative screen in North America. A case–control study was conducted with records from population‐based registries in New Mexico. Cases were women diagnosed with cervical cancer in 2006–2016, obtained from the Tumor Registry. Five controls per case from the New Mexico HPV Pap Registry were matched to cases by sex, age and place of residence. Dates and results of all cervical screening and diagnostic tests since 2006 were identified from the pap registry. We estimated the odds ratio of nonlocalized (Stage II+) and localized (Stage I) cervical cancer associated with attending screening in the 3 years prior to case‐diagnosis compared to women not screened in 5 years. Of 876 cases, 527 were aged 25–64 years with ≥3 years of potential screening data. Only 38% of cases and 61% of controls attended screening in a 3‐year period. Women screened in the 3 years prior to diagnosis had 83% lower risk of nonlocalized cancer (odds ratio [OR] = 0.17, 95% CI: 0.12–0.24) and 48% lower odds of localized cancer (OR = 0.52, 95% CI: 0.38–0.72), compared to women not screened in the 5 years prior to diagnosis. Women remained at low risk of nonlocalized cancer for 3.5–5 years after a negative screen compared to women with no negative screens in the 5 years prior to diagnosis. Routine cervical screening is effective at preventing localized and nonlocalized cervical cancers; 3 yearly screening prevents 83% of nonlocalized cancers, with no additional benefit of more frequent screening. Increasing screening coverage remains essential to further reduce cervical cancer incidence.

Pathogenic role of exosomes and microRNAs in HPV‐mediated inflammation and cervical cancer: A review

Cervical cancer (CC) is the fourth most common cause of cancer death in women. The most important risk factor for the development of CC is cervical infection with human papilloma virus (HPV). Inflammation is a protective strategy that is triggered by the host against pathogens such as viral infections that acts rapidly to activate the innate immune response. Inflammation is beneficial if it is brief and well controlled; however, if the inflammation is excessive or it becomes of chronic duration, it can produce detrimental effects. HPV proteins are involved, both directly and indirectly, in the development of chronic inflammation, which is a causal factor in the development of CC. However, other factors may also have a potential role in stimulating chronic inflammation. MicroRNAs (miRNAs) (a class of noncoding RNAs) are strong regulators of gene expression. They have emerged as key players in several biological processes, including inflammatory pathways. Abnormal expression of miRNAs may be linked to the induction of inflammation that occurs in CC. Exosomes are a subset of extracellular vesicles shed by almost all types of cells, which can function as cargo transfer vehicles. Exosomes contain proteins and genetic material (including miRNAs) derived from their parent cells and can potentially affect recipient cells. Exosomes have recently been recognized to be involved in inflammatory processes and can also affect the immune response. In this review, we discuss the role of HPV proteins, miRNAs and exosomes in the inflammation associated with CC.

Approaches to triage optimization in HPV primary screening: Extended genotyping and p16/Ki‐67 dual‐stained cytology—Retrospective insights from ATHENA

The objective of our study was to assess the performance of different triage strategies for high‐risk human papillomavirus (hrHPV)‐positive results utilizing either extended genotyping or a p16/Ki‐67 dual‐stained cytology (DS) approach, with or without partial genotyping. A subset of women with hrHPV infections participating in the Addressing the Need for Advanced HPV Diagnostics (ATHENA) study were analyzed to determine the number of cervical intraepithelial neoplasia grade 3 or worse (≥CIN3) cases detected, and the absolute risk for ≥CIN3 of each genotype. A clinical utility table was constructed to compare the impact of different triage strategies. In all, 2,339 women with single‐genotype hrHPV infections were identified. Among these were 171 ≥CIN3 cases. The U.S. Food and Drug Administration (FDA)‐approved algorithm (HPV16/18 positive, or 12‐other hrHPV positive and Pap positive, i.e., ≥ atypical squamous cells of undetermined significance) for primary HPV screening detected 132/171 (77.2%) ≥CIN3 cases and required 964 colposcopies (colposcopies per ≥CIN3 ratio: 7.3). An approach that uses DS instead of cytology in the FDA‐approved algorithm detected 147/171 (86.0%) ≥CIN3 cases, requiring 1,012 colposcopies (ratio: 6.9). Utilizing DS for triage of all hrHPV‐positive women identified 126/171 (73.7%) ≥CIN3 cases, requiring 640 colposcopies (ratio: 5.1). A strategy that detected HPV16/18/31/33/35+ captured 130/171 (76.0%) ≥CIN3 cases, requiring 1,025 colposcopies (ratio: 7.9). Inclusion of additional genotypes resulted in greater disease detection at the expense of higher colposcopy ratios. Substituting cytology with a DS triage approach improved disease detection and the colposcopy detection rate. Further reduction of colposcopy rates can be achieved by using DS without partial genotyping. Extended genotyping strategies can identify a comparable number of cases but requires an increased number of colposcopies.

Cervical cancer risk in women living with HIV across four continents: A multicohort study

We compared invasive cervical cancer (ICC) incidence rates in Europe, South Africa, Latin and North America among women living with HIV who initiated antiretroviral therapy (ART) between 1996 and 2014. We analyzed cohort data from the International Epidemiology Databases to Evaluate AIDS (IeDEA) and the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE) in EuroCoord. We used flexible parametric survival models to determine regional ICC rates and risk factors for incident ICC. We included 64,231 women from 45 countries. During 320,141 person‐years (pys), 356 incident ICC cases were diagnosed (Europe 164, South Africa 156, North America 19 and Latin America 17). Raw ICC incidence rates per 100,000 pys were 447 in South Africa (95% confidence interval [CI]: 382–523), 136 in Latin America (95% CI: 85–219), 76 in North America (95% CI: 48–119) and 66 in Europe (95% CI: 57–77). Compared to European women ICC rates at 5 years after ART initiation were more than double in Latin America (adjusted hazard ratio [aHR]: 2.43, 95% CI: 1.27–4.68) and 11 times higher in South Africa (aHR: 10.66, 95% CI: 6.73–16.88), but similar in North America (aHR: 0.79, 95% CI: 0.37–1.71). Overall, ICC rates increased with age (>50 years vs. 16–30 years, aHR: 1.57, 95% CI: 1.03–2.40) and lower CD4 cell counts at ART initiation (per 100 cell/μl decrease, aHR: 1.25, 95% CI: 1.15–1.36). Improving access to early ART initiation and effective cervical cancer screening in women living with HIV should be key parts of global efforts to reduce cancer‐related health inequities.

Cervical cancer case–control audit: Results from routine evaluation of a nationwide cervical screening program

Our study used a refined case–control cervical cancer Audit framework to investigate effectiveness of cervical screening, with measures of three screening failures: irregular‐participation, cervical cancer developed after cytological abnormalities and after normal screening results. The register‐based study included 4,254 cervical cancer cases diagnosed in Sweden during 2002–2011, and 30 population‐based controls per case. We used conditional logistic regression models to examine relative risks of cervical cancer in relation to screening participation and screening results in the past two screening rounds from 6 months before cancer diagnosis. We found that women unscreened in past two screening rounds showed four times increased risk of cervical cancer compared to women screened in time (OR = 4.1, 95% CI = 3.8–4.5), and women unscreened in the previous round but screened in the most recent round also showed a statistically significantly elevated risk (OR = 1.6, 95% CI = 1.5–1.8). Women having abnormality in previous two rounds exhibited higher risk of cervical cancer compared to women screened with normal results, while having normal results in the subsequent round after the abnormality also yielded an increased risk (OR = 4.0, 95% CI = 3.2–5.1). Being screened with only normal results was associated with 89% risk reduction for squamous cell cancer, compared to women unscreened, but only 60% reduction for adenocarcinoma. Our findings emphasize the importance of routine participation in cervical screening and suggest that management of abnormalities, as well as sensitivity of the test, warrants improvement especially for preventing cervical adenocarcinoma. The Audit framework serves as routine evaluation model and the findings benchmark for future evaluation of changes in screening practice.

Race‐specific temporal trends of HPV ‐related cancers in South Africa: An analysis of the South African National Cancer Registry, 2011–2022

Abstract Evaluating trends in HPV‐related cancer rates by race is essential for identifying high‐risk populations and improving prevention efforts. Using 2011–2022 South African National Cancer Registry data, we analyzed age‐standardized incidence rates by race and sex across three periods (2011–2014, 2015–2018, 2019–2022) using linear regression. Significant increases were observed for oropharyngeal squamous cell carcinoma (SCC) among White females ( p  < .01), vulvar SCC among Asian ( p  < .01) and Black ( p  = .02) females, and anal SCC among Colored females and Black males ( p  < .01). Cervical carcinoma rates remained stable for most racial groups, except for the annual trends showing a 1.9% increase per year (95% CI = 1.0, 2.7) among White females. These findings suggest rising incidence rates for some HPV‐related cancers across racial groups in South Africa. Further research is needed to explore the constellation of risk factors contributing to these trends and to guide targeted interventions.

Prognostic impact of p16 and high‐risk HPV DNA in ~1300 patients with vulvar cancer

AbstractThe study aimed to investigate whether vulvar squamous cell carcinoma (VSCC) survival varies by human papillomavirus (HPV) status measured by p16 expression and to determine whether high‐risk HPV (hrHPV) DNA detection adds further prognostic information. Our cohort included 1277 women with histologically verified VSCC (1990–2017) categorized according to p16 and hrHPV DNA. Crude survival was estimated using Kaplan–Meier, and differences in restricted mean survival time were estimated in linear regression models. Analyses were stratified by p16 and p16/hrHPV status and stage, and adjustment included age, calendar year, and comorbidity. Overall analysis showed that 5‐year survival was 67% (95% CI: 63–71%) and 45% (95% CI: 42–48%) in p16‐positive and p16‐negative VSCC, respectively. Overall, detection of hrHPV was associated with a 23% (95% CI: 6–40%) improvement in 5‐year survival in p16‐positive VSCC, whereas hrHPV status did not impact 5‐year survival in p16‐negative VSCC. In adjusted analysis, the survival difference by p16 status increased with increasing stage with a 26% (95% CI: 4–46%) higher 5‐year survival in FIGO IV disease if the tumor was p16‐positive compared to p16‐negative, corresponding to a restricted mean survival time difference of 18 months in favor of p16 positivity. The largest VSCC cohort to date confirms the beneficial prognostic impact of p16 expression regardless of age and comorbidity and with the greatest impact in women with advanced disease. Classification according to p16 was adequate for p16‐negative VSCC, whereas the survival of p16‐positive VSCC was higher if hrHPV testing was also positive.

Genomic profiling of the residual disease of advanced high‐grade serous ovarian cancer after neoadjuvant chemotherapy

The goal of our study was to demonstrate the spectrum of genomic alterations present in the residual disease of patients with advanced high‐grade serous ovarian cancer (HGSOC) after neoadjuvant chemotherapy (NAC), including matched pretreatment biopsies. During the study period between 2006 and 2017, we collected pre‐NAC and post‐NAC tumor tissue samples from patients with advanced HGSOC. We performed combined next‐generation sequencing and immunohistochemistry to identify actionable targets and pathway activation in post‐NAC residual tumors. We also examined whether post‐NAC profiling of residual HGSOC identified targetable molecular lesions in the chemotherapy‐resistant component of tumors. Among 102 post‐NAC samples, 41 (40%) of patients had mutations in homologous recombination repair (HRR) genes (HRR deficiency). Patients with HRR mutations had higher tumor mutation burdens (p < 0.001) and higher alterations in the PI3K–AKT–mTOR pathway (p = 0.004) than patients without these HRR mutations. Nevertheless, we found no significant differences in progression‐free survival (p = 0.662) and overall survival (OS; p = 0.828) between the two groups. Most patients (91%) had alterations in at least one of the targetable pathways, and those patients with cell cycle (p = 0.004) and PI3K–AKT–mTOR signaling (p = 0.005) pathway alterations had poorer OS (Bonferroni‐corrected threshold = 0.0083, 0.05/6). We showed the genomic landscape of tumor cells remaining in advanced HGSOC after NAC. Once validated, these data can help inform biomarker‐driven adjuvant studies in targeting residual tumors to improve the outcomes of patients with advanced HGSOC after NAC.

Biopsy‐verified vulvar lichen sclerosus: Incidence trends 1997–2022 and increased risk of vulvar squamous precancer and squamous cell carcinoma

AbstractPopulation‐based data on the epidemiology of vulvar lichen sclerosus (LS) are sparse and only few prospective studies have investigated the malignant potential of the disease. We used the nationwide Danish Pathology Registry to first assess the incidence of biopsy‐verified vulvar LS in the period 1997–2022 and second to examine the incidence of vulvar high‐grade squamous precancer and squamous cell carcinoma (SCC) in women with biopsy‐verified vulvar LS (1978–2019) compared with that expected in the general female population. For the latter aim, we computed standardized incidence ratios (SIRs) with 95% confidence intervals (CIs). During our study period, the age‐standardized incidence rate of vulvar LS increased from 5.0 (1997–1998) to 35.7 (2021–2022) per 100,000 person‐years. Compared with the general female population, women with biopsy‐verified vulvar LS had significantly increased rates of vulvar high‐grade squamous precancer (SIR = 8.5; 95% CI: 7.2–10.0) and SCC (SIR = 16.2; 95% CI: 14.2–18.4). The SIRs of vulvar high‐grade squamous precancer and SCC did not vary substantially according to length of follow‐up. This nationwide and population‐based study shows a 7‐fold increase in the incidence of biopsy‐verified vulvar LS since 1997. Data also show that women with biopsy‐verified vulvar LS have 8.5 and 16 times higher than expected incidence of vulvar high‐grade squamous precancer and SCC, respectively. The substantially increased incidence of vulvar high‐grade squamous precancer and SCC following LS is important in relation to the clinical management and follow‐up of LS patients.

Biopsy‐verified vulvar lichen sclerosus and the risk of non‐vulvar cancer: A nationwide cohort study

AbstractVulvar lichen sclerosus (VLS) is a chronic inflammatory mucocutaneous disease known to be associated with human papillomavirus‐independent vulvar squamous cell carcinoma. Evidence on the association with other types of cancer, however, is sparce. We conducted a large nationwide cohort study examining the incidence of non‐vulvar cancers among women with biopsy‐verified VLS compared with the general female population. By using the nationwide Pathology Registry, we identified all women in Denmark with a biopsy‐verified VLS diagnosis during 1978–2019 (n = 16,921). The cohort was followed up in the Danish Cancer Registry until 2022 for a subsequent non‐vulvar cancer diagnosis. Standardized incidence ratios (SIRs) were computed with 95% confidence intervals (CIs) as relative risk estimates of all specific non‐vulvar cancer sites. Compared with general female population rates, women with biopsy‐verified VLS had decreased rates of several non‐vulvar cancers, including HPV‐related cancers (combined estimate: SIR = 0.5; 95% CI: 0.3–0.7), and lung (SIR = 0.6; 95% CI: 0.5–0.7), liver (SIR = 0.5; 95% CI: 0.2–0.9), and thyroid cancer (SIR = 0.5; 95% CI: 0.3–0.9). The decreased SIRs tended to sustain throughout the follow‐up period following the VLS diagnosis. This large nationwide cohort study shows that women with biopsy‐verified VLS may have a long‐term reduced risk of developing HPV‐related (cervical, vaginal, oropharyngeal, and anal) and smoking‐associated cancers (lung, liver, and cervical) as well as thyroid cancer. Future studies focusing on the mechanisms behind the decreased cancer risk are needed.

Immune landscape of vulvar cancer patients treated with surgery and adjuvant radiotherapy revealed restricted T cell functionality and increased IL‐17 expression associated with cancer relapse

AbstractFor vulvar cancers, radiotherapy is targeting cancer cells, but also affects the host immune system. As this may affect treatment outcome, in this prospective study, we characterized the individual T cell immune milieu induced by surgery and adjuvant radio +/− chemotherapy (aRT) systemically in the blood of vulvar cancer patients and found increased frequencies of Interleukin (IL)‐17‐producing CD4+ and CD8+ T cells after aRT while frequencies of Th1 and perforin‐producing CD8+ killer cells were strongly diminished. Phenotypic characterization revealed enhanced expression of the ectonucleotidase CD39 on Th17 and Tc17 cells as well as CD8+ perforin+ cells after aRT. Furthermore, the aRT cohort exhibited increased proportions of Programmed Cell Death Protein (PD‐1) expressing cells among Th1 and CD8+ perforin+ cells, but not among Th17 and Tc17 cells. High post‐therapeutic levels of Th17 and Tc17 cells and low proportions of Th1 and CD8+ perforin+ cells expressing PD‐1 was associated with reduced recurrence free survival on follow‐up. In conclusion, our study defines individual therapy‐induced changes in the cellular immune milieu of patients and their association with cancer relapse. Our results may help to explain differences in the individual courses of disease of vulvar cancer patients and suggest PD‐1 and IL‐17 as targets for immunotherapy in vulvar cancer.

Clinical validation of methylation biomarkers for optimal detection of high‐grade vulvar intraepithelial neoplasia

Abstract The precursor lesions of vulvar squamous cell carcinoma (VSCC) include human papillomavirus (HPV)‐associated and HPV‐independent squamous neoplasia with a varying cancer risk. Our study aimed to validate the accuracy of previously identified DNA methylation markers for detection of such high‐grade vulvar intraepithelial neoplasia (VIN). A large clinical series of 751 vulvar lesions, originally diagnosed as high‐grade VIN, were reassessed and categorized into HPV‐associated or HPV‐independent vulvar disease categories. Together with 113 healthy vulvar controls, all samples were tested for 12 methylation markers with quantitative multiplex methylation‐specific PCR (qMSP). Performance of individual markers and selection of an optimal marker panel for detection of high‐grade VIN was determined by logistic regression analysis. SST was the best‐performing individual marker (AUC 0.90), detecting 80% of high‐grade VIN cases, with excellent detection of HPV‐independent VIN (95%), known to have the highest cancer risk. Merely 2% of controls tested methylation positive for SST . Selection of a marker panel, including ZNF582 , SST and miR124‐2 , resulted in a comparably high accuracy for detection of high‐grade VIN (AUC 0.89). In conclusion, we clinically validated the accuracy of 12 DNA methylation markers for detection of high‐grade VIN. SST , as a sole marker or in a panel, provides an optimal diagnostic tool to distinguish high‐grade VIN in need of treatment, particularly HPV‐independent VIN, from low‐grade or reactive vulvar lesions. These findings warrant further prognostic validation of methylation biomarkers for cancer risk stratification of patients with VIN.

Differential etiopathogenic features of vulvar squamous cell carcinomas in sub‐Saharan Africa and Europe

AbstractTwo pathways have been described for vulvar squamous cell carcinomas (VSCC), one associated with human papillomavirus (HPV), and the other HPV‐independent. We compared the etiopathogenic features of a series of VSCC from Mozambique, a sub‐Saharan country with high prevalence of HPV and HIV, with those of Spain, a European country with low prevalence of HPV and HIV. All VSCC diagnosed at the two institutions from January 2018 to December 2020 were included (n = 35 and n = 41, respectively). HPV DNA detection and genotyping, and immunohistochemistry for p16 and p53 were performed. Tumors showing p16 positive staining and/or HPV DNA positivity were considered HPV‐associated. 34/35 tumors (97%) from Mozambique and 8/41 (19%) from Spain were HPV‐associated (P < .001). Mean age of the patients from Mozambique and Spain was 45 ± 12 and 72 ± 14, respectively (P < .001). No differences were found in terms of HPV genotypes or multiple HPV infection rates. 1/35 tumors (3%) from Mozambique and 29/41 (70%) from Spain showed abnormal p53 immunostaining (P < .001). In contrast with the predominance of HPV‐independent VSCC affecting old women in Europe, most VSCC in sub‐Saharan Africa are HPV‐associated and arise in young women. This data may have important consequences for primary prevention of VSCC worldwide.

Effects of Metformin on the virus/host cell crosstalk in human papillomavirus‐positive cancer cells

AbstractOncogenic types of human papillomaviruses (HPVs) are major human carcinogens. The viral E6/E7 oncogenes maintain the malignant growth of HPV‐positive cancer cells. Targeted E6/E7 inhibition results in efficient induction of cellular senescence, which could be exploited for therapeutic purposes. Here we show that viral E6/E7 expression is strongly downregulated by Metformin in HPV‐positive cervical cancer and head and neck cancer cells, both at the transcript and protein level. Metformin‐induced E6/E7 repression is glucose and PI3K‐dependent but—other than E6/E7 repression under hypoxia—AKT‐independent. Proteome analyses reveal that Metformin‐induced HPV oncogene repression is linked to the downregulation of cellular factors associated with E6/E7 expression in HPV‐positive cancer biopsies. Notably, despite efficient E6/E7 repression, Metformin induces only a reversible proliferative stop in HPV‐positive cancer cells and enables them to evade senescence. Metformin also efficiently blocks senescence induction in HPV‐positive cancer cells in response to targeted E6/E7 inhibition by RNA interference. Moreover, Metformin treatment enables HPV‐positive cancer cells to escape from chemotherapy‐induced senescence. These findings uncover profound effects of Metformin on the virus/host cell interactions and the phenotype of HPV‐positive cancer cells with implications for therapy‐induced senescence, for attempts to repurpose Metformin as an anticancer agent and for the development of E6/E7‐inhibitory therapeutic strategies.

The development of “automated visual evaluation” for cervical cancer screening: The promise and challenges in adapting deep‐learning for clinical testing

AbstractThere is limited access to effective cervical cancer screening programs in many resource‐limited settings, resulting in continued high cervical cancer burden. Human papillomavirus (HPV) testing is increasingly recognized to be the preferable primary screening approach if affordable due to superior long‐term reassurance when negative and adaptability to self‐sampling. Visual inspection with acetic acid (VIA) is an inexpensive but subjective and inaccurate method widely used in resource‐limited settings, either for primary screening or for triage of HPV‐positive individuals. A deep learning (DL)‐based automated visual evaluation (AVE) of cervical images has been developed to help improve the accuracy and reproducibility of VIA as assistive technology. However, like any new clinical technology, rigorous evaluation and proof of clinical effectiveness are required before AVE is implemented widely. In the current article, we outline essential clinical and technical considerations involved in building a validated DL‐based AVE tool for broad use as a clinical test.

Acceleration of cervical cancer diagnosis with human papillomavirus testing below age 30: Observational study

AbstractSeveral international cervical screening guidelines advise against using high‐risk human papillomavirus (HR‐HPV) testing in women younger than 30. The rationale for this in young women, lies in the potential for additional detection of both low‐grade and high‐grade cervical intraepithelial neoplasia (CIN) leading to unnecessary treatments without reducing the burden of cervical cancer. We studied 56 544 women screened at 24 to 29 with HR‐HPV testing and 116 858 screened with liquid‐based cytology (LBC) in the English HPV screening pilot. They were compared to 528 460 women screened at the age of 30 to 49. We studied the detection of cervical cancer and CIN2/3 across two consecutive screening rounds 3 years apart. At 24 to 29, a positive HR‐HPV test detected more cases of cervical cancer in the prevalence round than did a positive LBC test (1.36/1000 screened vs 0.82/1000, ORadj: 1.61, 95% CI: 1.18‐2.19). In women with a negative HR‐HPV test, cervical cancer was diagnosed before or at the incidence round in 0.07/1000. After a negative LBC test, cancer detection reached 0.47/1000 and 40% of these cases were diagnosed at FIGO stage IB+. HR‐HPV testing increased the detection of CIN2/3 diagnoses in two consecutive rounds combined by 30% (71.9/1000 vs 55.2/1000). The patterns of detection of cervical cancer and CIN2/3 were almost identical at older ages. These data support using HR‐HPV testing for screening of women younger than 30, which not only accelerates the diagnosis of cervical cancer but leads to a similar relative increase in CIN2/3 diagnosis to that found in women aged 30 to 49.

Self‐sampling as the principal modality for population based cervical screening: Five‐year follow‐up of the PaVDaG study

AbstractSelf‐sampling provides a powerful means to engage women in cervical screening. In the original Papillomavirus Dumfries and Galloway study (PaVDaG), we demonstrated cross‐sectional similarity of high‐risk human papillomavirus (Hr‐HPV) testing on self‐taken vaginal vs clinician‐taken samples for the detection of cervical intraepithelial neoplasia 2 or worse (CIN2+). Few data exist on the longitudinal performance of self‐sampling; we present longitudinal outcomes of PaVDaG. Routinely screened women provided a self‐taken and a clinician‐collected sample. Ninety‐one percent of 5136 women from the original cohort completed a further screening round. Sensitivity, specificity, positive predictive value and complement of the negative predictive value of the Hr‐HPV test on self‐samples for detection of CIN2+ and CIN3+ up‐to 5 years after testing were determined. Additionally, clinical accuracy of Hr‐HPV testing on vaginal and clinician‐collected samples was assessed. A total of 183 CIN2+ and 102 CIN3+ lesions were diagnosed during follow‐up. Risk of CIN2+ and CIN3+ following an Hr‐HPV negative self‐sample was 0.6% and 0.2%, respectively, for up to 5 years after testing. The relative sensitivity for CIN3+ and specificity for ≤CIN1 of Hr‐HPV testing on self‐taken specimens was slightly lower vs clinician‐collected samples: 0.95 (95% CI: 0.90‐0.99; PMcN = .0625) and 0.98 (95% CI: 0.95‐1.00; PMcN = <.0000), respectively. The low risk of CIN2+ in women with Hr‐HPV—self‐sample(s) suggests, that the 3 to 5‐year recall interval implemented in several cervical screening settings, based on clinician‐taken samples, may be safe for self‐samples. Future assessment will show if “universal” 5‐year screening is appropriate for programs based on self‐sampling.

Vulvar intraepithelial neoplasia: Incidence and long‐term risk of vulvar squamous cell carcinoma

AbstractThe risk of vulvar squamous cell carcinoma (VSCC) in patients with high‐grade vulvar intraepithelial neoplasia (VIN) is considered lower in high‐grade squamous intraepithelial lesion (HSIL) compared to differentiated VIN (dVIN), but studies are limited. Our study investigated both the incidence of high‐grade VIN and the cumulative incidence of VSCC in patients with HSIL and dVIN separately. A database of women diagnosed with high‐grade VIN between 1991 and 2011 was constructed with data from the Dutch Pathology Registry (PALGA). The European standardized incidence rate (ESR) and VSCC risk were calculated, stratified for HSIL and dVIN. The effects of type of VIN (HSIL vs dVIN), age and lichen sclerosis (LS) were estimated by Cox regression. In total, 1148 patients were diagnosed with high‐grade VIN between 1991 and 2011. Between 1991‐1995 and 2006‐2011, the ESR of HSIL increased from 2.39 (per 100 000 woman‐years) to 3.26 and the ESR of dVIN increased from 0.02 to 0.08. The 10‐year cumulative VSCC risk was 10.3%; 9.7% for HSIL and 50.0% for dVIN (log rank P < .001). Type of VIN, age and presence of LS were independent risk factors for progression to VSCC, with hazard ratios of 3.0 (95% confidence interval [CI] 1.3‐7.1), 2.3 (95% CI 1.5‐3.4) and 3.1 (95% CI 1.8‐5.3), respectively. The incidence of high‐grade VIN is rising. Because of the high cancer risk in patients with dVIN, better identification and timely recognition are urgently needed.

Potential effectiveness of a therapeutic HPV intervention campaign in Uganda

AbstractCervical cancer is a major source of morbidity and mortality in Uganda. In addition to prophylactic HPV vaccination, secondary prevention strategies are needed to reduce cancer burden. We evaluated the potential cancer reductions associated with a hypothetical single‐contact therapeutic HPV intervention—with 70% coverage and variable efficacy [30%‐100%]—using a three‐stage HPV modeling framework reflecting HPV and cervical cancer burden in Uganda. In the reference case, we assumed prophylactic preadolescent HPV vaccination starting in 2020 with 70% coverage. A one‐time therapeutic intervention targeting 35‐year‐old women in 2025 (not age‐eligible for prophylactic vaccination) averted 1801 cervical cancers per 100 000 women over their lifetime (100% efficacy) or 533 cancers per 100 000 (30% efficacy). Benefits were considerably smaller in birth cohorts eligible for prophylactic HPV vaccination (768 cases averted per 100 000 at 100% efficacy). Evaluating the population‐level impact over 40 years, we found introduction of a therapeutic intervention in 2025 with 100% efficacy targeted annually to 30‐year‐old women averted 139 000 incident cervical cancers in Uganda. This benefit was greatly reduced if efficacy was lower (30% efficacy; 41 000 cases averted), introduction was delayed (2040 introduction; 72 000 cases averted) or both (22 000 cases averted). We demonstrate the potential benefits of a single‐contact HPV therapeutic intervention in a low‐income setting, but show the importance of high therapeutic efficacy and early introduction timing relative to existing prophylactic programs. Reduced benefits from a less efficacious intervention may be somewhat offset if available within a shorter time frame.

Age‐specific burden of cervical cancer associated with HIV: A global analysis with a focus on sub‐Saharan Africa

AbstractHIV substantially worsens human papillomavirus (HPV) carcinogenicity and contributes to an important population excess of cervical cancer, particularly in sub‐Saharan Africa (SSA). We estimated HIV‐ and age‐stratified cervical cancer burden at a country, regional and global level in 2020. Proportions of cervical cancer (a) diagnosed in women living with HIV (WLHIV), and (b) attributable to HIV, were calculated using age‐specific estimates of HIV prevalence (UNAIDS) and relative risk. These proportions were validated against empirical data and applied to age‐specific cervical cancer incidence (GLOBOCAN 2020). HIV was most important in SSA, where 24.9% of cervical cancers were diagnosed in WLHIV, and 20.4% were attributable to HIV (vs 1.3% and 1.1%, respectively, in the rest of the world). In all world regions, contribution of HIV to cervical cancer was far higher in younger women (as seen also in empirical series). For example, in Southern Africa, where more than half of cervical cancers were diagnosed in WLHIV, the HIV‐attributable fraction decreased from 86% in women ≤34 years to only 12% in women ≥55 years. The absolute burden of HIV‐attributable cervical cancer (approximately 28 000 cases globally) also shifted toward younger women: in Southern Africa, 63% of 5341 HIV‐attributable cervical cancer occurred in women <45 years old, compared to only 17% of 6901 non‐HIV‐attributable cervical cancer. Improved quantification of cervical cancer burden by age and HIV status can inform cervical cancer prevention efforts in SSA, including prediction of the impact of WLHIV‐targeted vs general population approaches to cervical screening, and impact of HIV prevention.

Nuclear transport proteins are secreted by cancer cells and identified as potential novel cancer biomarkers

AbstractPrevious studies have identified increased expression of members of the nuclear transport protein family in cancer cells. Recently, certain nuclear transport proteins have been reported to be secreted by cells and found in the serum. The aims of our study were to investigate the levels of multiple nuclear transport proteins secreted from cancer cells, and to determine their potential as diagnostic markers for cervical and oesophageal cancer. Mass spectrometry identified 10 nuclear transport proteins in the secretome and exosomes of cultured cancer cells, and Western blot analysis confirmed increased secreted levels in cancer cells compared to normal. To investigate their presence in patient serum, enzyme‐linked immunosorbent assays were performed and revealed significantly increased levels of KPNβ1, CRM1, CAS, IPO5 and TNPO1 in cervical and oesophageal cancer patient serum compared to non‐cancer controls. Significantly elevated KPNα2 and RAN levels were also identified in oesophageal cancer serum samples. Logistics regression analyses revealed IPO5 and TNPO1 to be the best performing individual candidate biomarkers in discriminating between cancer cases and controls. The combination of KPNβ1, CRM1, KPNα2, CAS, RAN, IPO5 and TNPO1 as a panel of biomarkers had the highest diagnostic capacity with an area under the curve of 0.944 and 0.963, for cervical cancer and oesophageal cancer, and sensitivity of 92.5% at 86.8% specificity and 95.3% sensitivity at 87.5% specificity, respectively. These results suggest that nuclear transport proteins have potential as diagnostic biomarkers for cervical and oesophageal cancers, with a combination of protein family members being the best predictor.

Performance of DNA methylation analysis of ASCL1, LHX8, ST6GALNAC5, GHSR, ZIC1 and SST for the triage of HPV‐positive women: Results from a Dutch primary HPV‐based screening cohort

AbstractMethylation of host‐cell deoxyribonucleic acid (DNA) has been proposed as a promising biomarker for triage of high‐risk (hr) human papillomavirus (HPV) positive women at screening. Our study aims to validate recently identified host‐cell DNA methylation markers for triage in an hrHPV‐positive cohort derived from primary HPV‐based cervical screening in The Netherlands. Methylation markers ASCL1, LHX8, ST6GALNAC5, GHSR, ZIC1 and SST were evaluated relative to the ACTB reference gene by multiplex quantitative methylation‐specific PCR (qMSP) in clinician‐collected cervical samples (n = 715) from hrHPV‐positive women (age 29‐60 years), who were enrolled in the Dutch IMPROVE screening trial (NTR5078). Primary clinical end‐point was cervical intraepithelial neoplasia grade 3 (CIN3) or cancer (CIN3+). The single‐marker and bi‐marker methylation classifiers developed for CIN3 detection in a previous series of hrHPV‐positive clinician‐collected cervical samples were applied. The diagnostic accuracy was visualised using receiver operating characteristic (ROC) curves and assessed through area under the ROC curve (AUC). The performance of the methylation markers to detect CIN3+ was determined using the predefined threshold calibrated at 70% clinical specificity. Individual methylation makers showed good performance for CIN3+ detection, with highest AUC for ASCL1 (0.844) and LHX8 (0.830). Combined as a bi‐marker panel with predefined threshold, ASCL1/LHX8 yielded a CIN3+ sensitivity of 76.9% (70/91; 95% CI 68.3‐85.6%) at a specificity of 74.5% (465/624; 95% CI 71.1‐77.9%). In conclusion, our study shows that the individual host‐cell DNA methylation classifiers and the bi‐marker panel ASCL1/LHX8 have clinical utility for the detection of CIN3+ in hrHPV‐positive women invited for routine screening.

Clinical validation of p16/Ki‐67 dual‐stained cytology triage of HPV‐positive women: Results from the IMPACT trial

AbstractTriage strategies are needed for primary human papillomavirus (HPV)‐based cervical cancer screening to identify women requiring colposcopy/biopsy. We assessed the performance of p16/Ki‐67 dual‐stained (DS) immunocytochemistry to triage HPV‐positive women and compared it to cytology, with or without HPV16/18 genotyping. A prospective observational screening study enrolled 35 263 women aged 25 to 65 years at 32 U.S. sites. Cervical samples had HPV and cytology testing, with colposcopy/biopsy for women with positive tests. Women without cervical intraepithelial neoplasia Grade 2 or worse (≥CIN2) at baseline (n = 3876) were retested after 1 year. In all, 4927 HPV‐positive women with valid DS results were included in this analysis. DS sensitivity for ≥CIN2 and ≥CIN3 at baseline was 91.2% (95% confidence interval [CI]: 86.8%‐94.2%) and 91.9% (95% CI: 86.1%‐95.4%), respectively, in HPV16/18‐positive women and 83.0% (95% CI: 78.4%‐86.8%) and 86.0% (95% CI: 77.5%‐91.6%) in women with 12 “other” genotypes. Using DS alone to triage HPV‐positive women showed significantly higher sensitivity and specificity than HPV16/18 genotyping with cytology triage of 12 “other” genotypes, and substantially higher sensitivity but lower specificity than using cytology alone. The risk of ≥CIN2 was significantly lower in HPV‐positive, DS‐negative women (3.6%; 95% CI: 2.9%‐4.4%), compared to triage‐negative women using HPV16/18 genotyping with cytology for 12 “other” genotypes (7.4%; 95% CI: 6.4%‐8.5%; P < .0001) or cytology alone (7.5%; 95% CI: 6.7%‐8.4%; P < .0001). DS showed better risk stratification than cytology‐based strategies and provided high reassurance against pre‐cancers both at baseline and at 1‐year follow‐up, irrespective of the HPV genotype. DS allows for the safe triage of primary screening HPV‐positive women.

Audit of laboratory sensitivity of human papillomavirus and cytology testing in a cervical screening program

AbstractThe globally recommended public health policy for cervical screening is primary human papillomavirus (HPV) screening with cytology triaging of positives. To ensure optimal quality of laboratory services we have conducted regular audits of cervical smears taken before cervical cancer or cancer in situ (CIN3+) within an HPV‐based screening program. The central cervical screening laboratory of Stockholm, Sweden, identified cases of CIN3+ who had had a previous cervical screening test up to 3 years before and randomly selected 300 cervical liquid‐based cytology (LBC) samples for auditing. HPV testing with Roche Cobas was performed either at screening or with biobanked samples. HPV negative samples and subsequent biopsies were retrieved and tested with modified general primer HPV PCR and, if still HPV‐negative, the LBCs and biopsies were whole genome sequenced. The Cobas 4800 detected HPV in 1020/1052 (97.0%) LBC samples taken before CIN3+. Further analyses found HPV in 28 samples, with nine of those containing HPV types not targeted by the Cobas 4800 test. There were 4 specimens (4/1052, 0.4%) where no HPV was detected. By comparison, the proportion of CIN3+ cases that were positive in a previous cytology were 91.6%. We find that the routine HPV screening test had a sensitivity in the real‐life screening program of 97.0%. Regular laboratory audits of cervical samples taken before CIN3+ can be readily performed within a real‐life screening program and provide assurance that the laboratory of the real‐life program has the expected performance.

The road to cervical cancer elimination in Malaysia: Evaluation of the impact and cost‐effectiveness of human papillomavirus screening with self‐collection and digital registry support

AbstractThe WHO has launched a global strategy to eliminate cervical cancer through the scale‐up of human papillomavirus (HPV) vaccination, cervical screening, and cervical cancer treatment. Malaysia has achieved high‐coverage HPV vaccination since 2010, but coverage of the existing cytology‐based program remains low. Pilot studies found HPV self‐sampling was acceptable and effective, with high follow‐up rates when a digital registry was used, and recently the Malaysian Government announced plans for a national HPV‐based screening program. We therefore evaluated the impact of primary HPV screening with self‐collection in Malaysia in the context of Malaysia's existing vaccination program. We used the “Policy1‐Cervix” modeling platform to assess health outcomes, cost‐effectiveness, resource use and cervical cancer elimination timing (the year when cervical cancer rates reach four cases per 100 000 women) of implementing primary HPV testing with self‐collection, assuming 70% routine‐screening coverage could be achieved. Based on available data, we assumed that compliance with follow‐up was 90% when a digital registry was used, but that compliance with follow‐up would be 50‐75% without the use of a digital registry. We found that the current vaccination program would prevent 27 000 to 32 200 cervical cancer cases and 11 700 to 14 000 deaths by 2070. HPV testing with a digital registry was cost‐effective (CER = $US 6953‐7549 < $US 11 373[<1×GDP per capita]) and could prevent an additional 15 900 to 17 800 cases and 9700 to 10 600 deaths by 2070, expediting national elimination by 11 to 20 years, to 2055 to 2059. If HPV screening were implemented without a digital registry, there would be 1800 to 4900 fewer deaths averted by 2070 and the program would be less cost‐effective. These results underline the importance of HPV testing as a key elimination pillar in Malaysia.

Human papillomavirus load and genotype analysis improves the prediction of invasive cervical cancer

AbstractHuman papillomavirus (HPV)‐based cervical screening is a globally recommended health policy. Different HPV types have different risk for cervical cancer. For optimal HPV screening, the sensitivity and specificity for each HPV type at different viral loads should be known in a screening setting. HPV test results in about 1 million cervical samples analyzed during 2006 to 2014 were compared for 319 women who had developed invasive cervical cancer up to 8.5 years later and for 1911 matched control women. Detection including low viral loads resulted in markedly increased sensitivity for cervical cancer only for HPV types 16 and 18. Testing for HPV types 31, 33, 45 and 52 also increased the sensitivity for prediction of cervical cancer, but for these viruses, detection of low viral load did not further increase sensitivity. HPV types 35, 39, 51, 56, 58, 59, 66 and 68 only predicted occasional additional cervical cancer cases. Testing for HPV16/18 at low viral load plus testing for HPV31, 33, 45 and 52 at >3000 copies/μL predicted 86.5% of cancers occurring within a year after testing, similar to the 89.4% that were predicted by testing for 14 HPV types. By contrast, the type and viral load‐restricted testing greatly increased specificity: 6.3% of healthy women tested positive as compared to 11.7% of healthy women testing positive for the 14 HPV types commonly screened for today. Adequate HPV screening sensitivity, with considerable increase in specificity, can be obtained by testing only for HPV16/18/31/33/45/52, with detection of low viral load required only for HPV16/18.

The WID‐qEC test: Performance in a hospital‐based cohort and feasibility to detect endometrial and cervical cancers

AbstractThe majority of endometrial and cervical cancers present with abnormal vaginal bleeding but only a small proportion of women suffering from vaginal bleeding actually have such a cancer. A simple, operator‐independent and accurate test to correctly identify women presenting with abnormal bleeding as a consequence of endometrial or cervical cancer is urgently required. We have recently developed and validated the WID‐qEC test, which assesses DNA methylation of ZSCAN12 and GYPC via real‐time PCR, to triage women with symptoms suggestive of endometrial cancer using ThinPrep‐based liquid cytology samples. Here, we investigated whether the WID‐qEC test can additionally identify women with cervical cancer. Moreover, we evaluate the test's applicability in a SurePath‐based hospital‐cohort by comparing its ability to detect endometrial and cervical cancer to cytology. In a set of 23 cervical cancer cases and 28 matched controls the receiver operating characteristic (ROC) area under the curve (AUC) is 0.99 (95% confidence interval [CI]: 0.97‐1.00) with a sensitivity and specificity of 100% and 92.9%, respectively. Amongst the hospital‐cohort (n = 330), the ROC AUC is 0.99 (95% CI: 0.98‐1) with a sensitivity and specificity of 100% and 82.5% for the WID‐qEC test, respectively, and 33.3% and 96.9% for cytology (considering PAP IV/V as positive). Our data suggest that the WID‐qEC test detects both endometrial and cervical cancer with high accuracy.

Widening the offer of human papillomavirus self‐sampling to all women eligible for cervical screening: Make haste slowly

AbstractSelf‐collection of samples for human papillomavirus (HPV) testing has the potential to increase the uptake of cervical screening among underscreened women and will likely form a crucial part of the WHO's strategy to eliminate cervical cancer by 2030. In high‐income countries with long‐standing, organised cervical screening programmes, self‐collection is increasingly becoming available as a routine offer for women regardless of their screening histories, including under‐ and well‐screened women. For these contexts, a validated microsimulation model determined that adding self‐collection to clinician collection is likely to be cost‐effective on the condition that it meets specific thresholds relating to (1) uptake and (2) sensitivity for the detection of high‐grade cervical intraepithelial neoplasia (CIN2+). We used these thresholds to review the ‘early‐adopter’ programme‐level evidence with a mind to determine how well and how consistently they were being met. The available evidence suggested some risk to overall programme performance in the situation where low uptake among underscreened women was accompanied by a high rate of substituting clinician sampling with self‐collection among well‐screened women. Risk was further compounded in a situation where the slightly reduced sensitivity of self‐sampling vs clinician sampling for the detection of CIN2+ was accompanied with lack of adherence to a follow‐up triage test that required a clinician sample. To support real‐world programmes on their pathways toward implementation and to avoid HPV self‐collection being introduced as a screening measure in good faith but with counterproductive consequences, we conclude by identifying a range of mitigations and areas worthy of research prioritisation.

The current status of cell‐free human papillomavirus DNA as a biomarker in cervical cancer and other HPV‐associated tumors: A review

AbstractTumor cells release fragments of their DNA into the circulation, so called cell‐free tumor DNA (ctDNA), allowing for analysis of tumor DNA in a simple blood test, that is, liquid biopsy. Cervical cancer is one of the most common malignancies among women worldwide and high‐risk human papillomavirus (HR‐HPV) is the cause of the majority of cases. HR‐HPV integrates into the host genome and is often present in multiple copies per cell and should thus also be released as ctDNA. Such ctHPV DNA is therefore a possible biomarker in cervical cancer. In this review, we first give a background on ctDNA in general and then a comprehensive review of studies on ctHPV DNA in cervical cancer and pre‐malignant lesions that may develop in cervical cancer. Furthermore, studies on ctHPV DNA in other HPV related malignancies (eg, head‐and‐neck and anogenital cancers) are briefly reviewed. We conclude that detection of ctHPV DNA in plasma from patients with cervical cancer is feasible, although optimized protocols and ultra‐sensitive techniques are required for sufficient sensitivity. Results from retrospective studies in both cervical cancer and other HPV‐related malignancies suggests that ctHPV DNA is a promising prognostic biomarker, for example, for detecting relapses early. This paves the way for larger, preferably prospective studies investigating the clinical value of ctHPV DNA as a biomarker in cervical cancer. However, there are conflicting results whether ctHPV DNA can be found in blood from patients with pre‐malignant lesions and further studies are needed to fully elucidate this question.

Assessing the risk of cervical neoplasia in the post‐HPV vaccination era

AbstractThis review is based on the recent EUROGIN scientific session: “Assessing risk of cervical cancer in the post‐vaccination era,” which addressed the demands of cervical intraepithelial neoplasia (CIN)/squamous intraepithelial lesion (SIL) triage now that the prevalence of vaccine‐targeted oncogenic high‐risk (hr) human papillomaviruses (HPVs) is decreasing. Change in the prevalence distribution of oncogenic HPV types that follows national HPV vaccination programs is setting the stage for loss of positive predictive value of conventional but possibly also new triage modalities. Understanding the contribution of the latter, most notably hypermethylation of cellular and viral genes in a new setting where most oncogenic HPV types are no longer present, requires studies on their performance in vaccinated women with CIN/SIL that are associated with nonvaccine HPV types. Lessons learned from this research may highlight the potential of cervical cells for risk prediction of all women's cancers.

Dickkopf‐1 expression is repressed by oncogenic human papillomaviruses (HPVs) and regulates the Cisplatin sensitivity of HPV‐positive cancer cells in a JNK‐dependent manner

AbstractOncogenic human papillomavirus (HPV) types control the phenotype of cervical cancer cells through the sustained expression of the viral E6/E7 oncogenes. Here, we show that they strongly restrain expression of the putative tumor suppressor protein Dkk1 (Dickkopf‐1) in HPV‐positive cervical cancer cells through the restriction of p53 expression by the continuously expressed endogenous E6 oncoprotein. Moreover, our study reveals that compromised Dkk1 expression is linked to increased resistance of HPV‐positive cervical cancer cells toward the proapoptotic activity of Cisplatin. Although Dkk1 can act as a Wnt antagonist, the antiapoptotic effect resulting from Dkk1 repression is not linked to an activation of this pathway. Rather, transcriptome and functional analyses uncover that Dkk1 repression leads to a strongly diminished stimulation of c‐Jun N‐terminal kinase (JNK) signaling which is required for efficient apoptosis induction by Cisplatin in cervical cancer cells. Further, we observed that Dkk1‐depleted cervical cancer cells induce senescence under Cisplatin treatment instead of apoptosis, suggesting that Dkk1 levels can strongly influence the phenotypic response of these cells toward Cisplatin. Collectively, these results provide new insights into the virus/host cell crosstalk in cervical cancer cells by identifying Dkk1 as a cellular target which is maintained under strong negative control by the continuous expression of the HPV oncogenes. Moreover, they identify Dkk1 as a critical determinant for the sensitivity of cervical cancer cells toward Cisplatin, showing that Dkk1 repression leads to increased Cisplatin resistance by impairing proapoptotic JNK signaling.

Histopathological phenotyping of cancers in PTEN Hamartoma Tumor Syndrome for improved recognition: A single‐center study

AbstractPTEN hamartoma tumor syndrome (PHTS) has a broad clinical spectrum including various benign and malignant tumors at varying age of diagnosis. Many patients remain unrecognized, unaware of their increased cancer risk. We aimed to describe the cancer spectrum, age of onset and histopathological cancer characteristics to assess whether specific cancer characteristics could improve PHTS recognition. Genetic testing results and pathology reports were collected for patients tested for germline PTEN variants between 1997 and 2020 from the diagnostic laboratory and the Dutch nationwide pathology databank (Palga). The cancer spectrum and age of onset were assessed in patients with (PTENpos) and without (PTENneg) a germline PTEN variant. Histopathological cancer characteristics were assessed in a nested cohort. 341 PTENpos patients (56% females) and 2882 PTENneg patients (66% females) were included. PTENpos patients presented mostly with female breast (BC, 30%), endometrial (EC, 6%), thyroid (TC, 4%) or colorectal cancer (4%). PTENpos were significantly younger at cancer onset (43 vs. 47 years) and had more often (46% vs. 18%) a second BC than PTENneg. PTEN detection rates were highest for BC <40 years (9%), TC <20 years (15%) and EC <50 years (28%), and dropped to 6%, 4%, and 15% by age 60. Histopathological characteristics were similar between groups. No histopathological cancer characteristics were distinctive for PHTS. However, PTENpos were significantly younger at cancer onset. Therefore early‐onset BC, EC, or TC warrants consideration of PHTS diagnostics either through a pre‐screen for other PHTS features or direct germline testing.

Atypical glandular cells and development of cervical cancer: Population‐based cohort study

AbstractThe effect of cervical screening on cervical adenocarcinoma has been variable, possibly because the risk associated with the precursor atypical glandular cells (AGC) is not well known. A cohort of all 885 women in the capital region of Sweden with AGC, a concomitant human papillomavirus (HPV) analysis, and a histopathology was followed until 2019. Cumulative incidence proportions of cervical intraepithelial lesion grade 3 or worse (CIN3+) by HPV type was determined by 1‐Kaplan‐Meier estimates. Hazard ratios (HR) for CIN3+ or for invasive cancer were estimated with Cox regression. After 2 years of follow‐up, the cumulative incidence proportions of CIN3+ were 80% (95% confidence interval [CI]: 74‐86%), 58% (95% CI: 50‐60%) and 10% (95% CI: 5‐18%) among HPV16/18 positive, “other HPV” positive and HPV‐negative women, respectively. Among the 300 women with HPV16/18 positive AGC, 217 developed CIN3+ of which 35 were invasive cervical cancer. The 2‐year cumulative invasive cancer risk for HPV16/18 positive AGC was 17% (95% CI: 12‐24%). Primary HPV‐screening had a similar yield of CIN3+ as cytology screening, albeit HPV‐negative AGC is by design not detected by HPV screening. Among 241 women with HPV‐negative AGC, 11 developed CIN3+ mostly after clinically indicated samples. We found no significant risk differences depending on age or sampling indication. The low CIN3+ risk after HPV‐negative AGC implies safety of primary HPV screening. The high risk of invasive cervical cancer after HPV16/18 positive AGC implies that management of this finding is a priority in cervical screening.

Human papillomavirus self‐sampling with mRNA testing benefits routine screening

AbstractHigh risk human papillomavirus (hrHPV) based screening provides the possibility of vaginal self‐sampling as a tool to increase screening attendance. In order to evaluate the impact and feasibility of opt‐in self‐sampling in the Finnish setting, we invited a randomized population of 5350 women not attending screening after age group invitation or after reminder, to attend HPV self‐sampling‐based screening in the autumn of 2018 in Helsinki. Out of those, 1282 (24.0%) expressed their interest and ordered the sampling package. Eventually 787 women (14.7% of the total invited population) took part in screening, 770 women by providing a vaginal sample within 2 months from invitation and 17 by providing a pap smear in the laboratory. Self‐taken samples were collected in Aptima Multitest vials and tested using the Aptima HPV mRNA assay. A high proportion, 158/770 (20.5%) of the samples were positive in the Aptima HPV assay. One hundred and forty‐one samples were further submitted to Aptima HPV Genotyping and extended genotyping by a Luminex based assay. Of those, 23 samples (16.3%) were HPV 16 positive and 7 (5.0%) were positive for HPV 18/45; extended genotyping revealed multiple high‐risk and low‐risk HPV genotypes. At follow‐up seven cases of high‐grade squamous intraepithelial lesion (HSIL) were diagnosed, which represents 4.4% of HPV positive women and 0.9% of screened women, whereas the rate was 0.5% in routine screening. Our findings suggest that self‐sampling with HPV mRNA testing is a feasible approach to improve screening efficacy in a high‐risk population among original nonattendees.

Redesign of a rapid, low‐cost HPV typing assay to support risk‐based cervical screening and management

AbstractAccelerated cervical cancer control will require widespread human papillomavirus (HPV) vaccination and screening. For screening, sensitive HPV testing with an option of self‐collection is increasingly desirable. HPV typing predicts risk of precancer/cancer, which could be useful in management, but most current typing assays are expensive and/or complicated. An existing 15‐type isothermal amplification assay (AmpFire, Atila Biosystems, USA) was redesigned as a 13‐type assay (ScreenFire) for public health use. The redesigned assay groups HPV types into four channels with differential cervical cancer risk: (a) HPV16, (b) HPV18/45, (c) HPV31/33/35/52/58 and (d) HPV39/51/56/59/68. Since the assay will be most useful in resource‐limited settings, we chose a stratified random sample of 453 provider‐collected samples from a population‐based screening study in rural Nigeria that had been initially tested with MY09‐MY11‐based PCR with oligonucleotide hybridization genotyping. Frozen residual specimens were masked and retested at Atila Biosystems. Agreement on positivity between ScreenFire and prior PCR testing was very high for each of the channels. When we simulated intended use, that is, a hierarchical result in order of clinical importance of the type groups (HPV16 > 18/45 > 31/33/35/52/58 > 39/51/56/59/68), the weighted kappa for ScreenFire vs PCR was 0.90 (95% CI: 0.86‐0.93). The ScreenFire assay is mobile, relatively simple, rapid (results within 20‐60 minutes) and agrees well with reference testing particularly for the HPV types of greatest carcinogenic risk. If confirmed, ScreenFire or similar isothermal amplification assays could be useful as part of risk‐based screening and management.

Evaluation of FAM19A4/miR124‐2 methylation performance in the management of CIN3 diagnosed pregnant women

AbstractPregnant women diagnosed with CIN3 have high regression rates after delivery. Biomarkers are needed to only identify pregnant women with progressive CIN requiring treatment to reduce overreferral and overtreatment. In our study we evaluated the performance of the FAM19A4/miR124‐2 methylation test for molecular triage on FFPE samples of CIN3+‐diagnosed pregnant women with known clinical course over time as well in a cross‐sectional setting. In this German multicenter retrospective study biopsy material was collected from pregnant women diagnosed with cervical cancer (n = 16), with CIN3 that progressed to cancer during pregnancy (n = 7), with CIN3 that regressed to CIN1 or less within 6 months after delivery (n = 41), without CIN (n = 16), CIN3 covering 3‐4 quadrants (n = 14) and randomly selected CIN3 (n = 41). FAM19A4/miR124‐2 methylation analysis was performed blinded on first diagnosis. All pregnant women with cervical cancer and with CIN3 progressing to cancer tested positive for FAM19A4/miR124‐2 methylation (100%, 22/22). In the regressing CIN3 group 47.5% and in the group without CIN 21.6% tested methylation positive. High‐volume CIN3 and random selected CIN3 were methylation‐positive in 91.7% and 82.1%, respectively. Methylation levels were significantly higher in progressive CIN3 and cancer compared to the controls (P < .0005). The likelihood ratio of a negative methylation test (LR−) for progressive CIN3+ was 0 (95% CI: 0‐0.208). A negative FAM19A4/miR124‐2 methylation test can rule out progressive CIN disease in pregnant women diagnosed with CIN3. This can help the clinician by managing these pregnant women with conservative follow‐up until after delivery.

Now or later: Health impacts of delaying single‐dose HPV vaccine implementation in a high‐burden setting

AbstractWe aimed to quantify the health impact of immediate introduction of a single‐dose human papillomavirus (HPV) vaccination program in a high‐burden setting, as waiting until forthcoming trials are completed to implement single‐dose HPV vaccination may result in health losses, particularly for cohorts who would age‐out of vaccination eligibility. Two mathematical models fitted to a high‐burden setting projected cervical cancer incidence rates associated with (a) immediate implementation of one‐dose HPV vaccination vs (b) waiting 5 years for evidence from randomized trials to determine if one‐ or two‐doses should be implemented. We conducted analyses assuming a single dose was either noninferior or inferior to two doses. The models projected that immediate implementation of a noninferior single‐dose vaccine led to a 7.2% to 9.6% increase in cancers averted between 2021 to 2120, compared to waiting 5 years. Health benefits remained greater with immediate implementation despite an inferior single‐dose efficacy (80%), but revaccination of one‐dose recipients became more important assuming vaccine waning. Under most circumstances, immediate vaccination avoided health losses for those aging out of vaccine eligibility, leading to greater health benefits than waiting for more information in 5 years.

Human papillomavirus‐based screening at extended intervals missed fewer cervical precancers than cytology in the HPV For Cervical Cancer (HPV FOCAL) trial

AbstractWhile cervix screening using cytology is recommended at 2‐ to 3‐year intervals, given the increased sensitivity of human papillomavirus (HPV)‐based screening to detect precancer, HPV‐based screening is recommended every 4‐ to 5‐years. As organized cervix screening programs transition from cytology to HPV‐based screening with extended intervals, there is some concern that cancers will be missed between screens. Participants in HPV FOr CervicAL Cancer (HPV FOCAL) trial received cytology (Cytology Arm) at 24‐month intervals or HPV‐based screening (HPV Arm) at 48‐month intervals; both arms received co‐testing (cytology and HPV testing) at exit. We investigated the results of the co‐test to identify participants with cervical intraepithelial neoplasia grade 2 or higher (CIN2+) who would not have had their precancer detected if they had only their arm's respective primary screen. In the Cytology Arm, 25/62 (40.3%) identified CIN2+s were missed by primary screen (ie, normal cytology/positive HPV test) and all 25 had normal cytology at the prior 24‐month screen. In the HPV arm, three CIN2+s (3/49, 6.1%) were missed by primary screen (ie, negative HPV test/abnormal cytology). One of these three misses had low‐grade cytology findings and would also not have been referred to colposcopy outside of the trial. Multiple rounds of cytology did not detect some precancerous lesions detected with one round of HPV‐based screening. In our population, cytology missed more CIN2+, even at shorter screening intervals, than HPV‐based screening. This assuages concerns about missed detection postimplementation of an extended interval HPV‐based screening program. We recommend that policymakers consider a shift from cytology to HPV‐based cervix screening.

DNA methylation testing with S5 for triage of high‐risk HPV positive women

AbstractMethylation of host and viral genes is promising for triage of women with high‐risk human papillomavirus infections (hrHPV). Using a population‐based sample of hrHPV positive women with cervical biopsies within 12 months after cervical screening, the clinical value of the S5 methylation classifier (S5), HPV genotyping and cytology were compared as potential triage tests, for outcomes of cervical intraepithelial neoplasia (CIN) grade 3 or greater (CIN3+), CIN2+ and CIN2, and the area under the curve (AUC) calculated. S5 scores increased with histopathology severity (Ptrend < .001). For CIN3+, the AUC was 0.780 suggesting S5 provides good discrimination between <CIN3 and CIN3+. AUCs were significant for all pairwise comparisons of <CIN2, CIN2 and CIN3+ (P < .001). The positive predictive value (PPV) of HPV16/18 genotyping for women with any abnormal cytology was greater than S5 (25.36% vs 20.87%, P = .005) for CIN3+, while sensitivity was substantially greater for S5 (83.33% vs 59.28%, P < .001). Restricting to women with abnormal cytology, but excluding those with high‐grade cytology, both S5 and HPV16/18 provided CIN3+ PPVs high enough to recommend colposcopy. Triage with S5 also appeared useful for hrHPV positive women negative for HPV16/18 (CIN3+ PPV: 7.33%, sensitivity: 57.52%). S5 provided increased sensitivity for CIN3+ compared to HPV16/18 genotyping for hrHPV positive women, overall and when restricted to women with abnormal cytology, suggesting S5 may improve colposcopy referral. S5 also has the ability to distinguish between <CIN2, CIN2 and CIN3+, a finding of importance for managing CIN2, given the complexity and uncertainty associated with this diagnosis.

DNA methylation testing for endometrial cancer detection in urine, cervicovaginal self‐samples and cervical scrapes

AbstractEndometrial cancer incidence is rising and current diagnostics often require invasive biopsy procedures. DNA methylation marker analysis of minimally‐ and non‐invasive sample types could provide an easy‐to‐apply and patient‐friendly alternative to determine cancer risk. Here, we compared the performance of DNA methylation markers to detect endometrial cancer in urine, cervicovaginal self‐samples and clinician‐taken cervical scrapes. Paired samples were collected from 103 patients diagnosed with stage I to IV endometrial cancer. Urine and self‐samples were collected at home. All samples were tested for nine DNA methylation markers using quantitative methylation‐specific PCR. Methylation levels measured in endometrial cancer patients were compared to unpaired samples of 317 healthy controls. Diagnostic performances were evaluated by univariable and multivariable logistic regression analysis, followed by leave‐one‐out cross‐validation. Each methylation marker showed significantly higher methylation levels in all sample types of endometrial cancer patients compared to healthy controls (P < .01). Optimal three‐marker combinations demonstrated excellent diagnostic performances with area under the receiver operating curve values of 0.95 (95% CI: 0.92‐0.98), 0.94 (0.90‐0.97) and 0.97 (0.96‐0.99), for endometrial cancer detection in urine, self‐samples and scrapes, respectively. Sensitivities ranged from 89% to 93% at specificities of 90% to 92%. Virtually equal performances were obtained after cross‐validation and excellent diagnostic performances were maintained for stage I endometrial cancer detection. Our study shows the value of methylation analysis in patient‐friendly sample types for endometrial cancer detection of all stages. This approach has great potential to screen patient populations at risk for endometrial cancer.

The cervico‐vaginal DNA methylation WID ‐ qEC test: An epigenetic marker associated with ovarian cancer in the absence of endometrial and cervical cancer

Abstract The DNA methylation‐based WID‐qEC test, applied to cervico‐vaginal samples, has been validated for the accurate detection of endometrial and cervical cancers. However, a small proportion of women test positive despite the absence of these cancers. The aim of this study was to explore the biological and clinical characteristics associated with such WID‐qEC‐positive cases to inform potential follow‐up strategies. We analyzed 1269 cervico‐vaginal samples from women without endometrial or cervical cancer, including healthy controls ( n  = 624), women with benign gynecological conditions ( n  = 324), and ovarian cancer cases ( n  = 321). Of the 80 WID‐qEC‐positive results, 43 (54%) were from women with ovarian cancer. WID‐qEC positivity was associated with the presence of ovarian cancer (adjusted odds ratio [OR] 2.93; 95% CI 1.75–4.95) and with a higher number of lifetime ovulatory cycles (adjusted OR 2.67; 95% CI 1.06–7.50), a known ovarian cancer risk factor. Both associations were independent of age, menopausal status, hormone replacement therapy usage, or family history of breast or ovarian cancer. Our findings suggest that in the absence of endometrial or cervical cancer, WID‐qEC positivity may indicate an elevated risk or presence of ovarian cancer. While the standalone positive predictive value (PPV) for ovarian cancer detection remains low in the general population, we outline how WID‐qEC could be used in a two‐step triage approach. In women presenting with abnormal bleeding, combining WID‐qEC positivity with a highly specific plasma‐based cell‐free DNA methylation test (e.g., with 60%–80% sensitivity and ~98.4% specificity) could theoretically yield a PPV of around 30%–40%. This hypothetical modeling is intended solely to illustrate how WID‐qEC positivity might inform future triage research, rather than to propose a clinical diagnostic algorithm.

Detecting TP53 mutations in paired liquid and tissue biopsies from patients with high‐grade serous ovarian carcinoma

Abstract High‐grade serous ovarian carcinoma (HGSC) is the most lethal form of ovarian carcinoma, often diagnosed at advanced stages due to non‐specific symptoms and the lack of reliable screening methods. This proof‐of‐concept study aimed to develop a robust TP53 mutation panel for detecting HGSC through targeted DNA sequencing in both liquid and solid biopsies. We constructed a custom TP53 gene panel and utilized a PCR‐based unique molecular identifier approach for next‐generation sequencing to analyze 94 samples from 11 patients diagnosed with HGSC, including primary tumor, plasma, ascites, ovarian cyst fluid, vaginal, endocervical and endometrial samples. Detected TP53 mutations were analyzed, categorized, and their frequencies calculated. Pathogenic TP53 mutations were identified in all patients, with 91% of the patients exhibiting one unique paired mutation across three or more sample types. The panel demonstrated high sensitivity and technical reproducibility, successfully detecting TP53 mutations across all sample types, with as little as 2.6 ng of DNA. TP53 mutations were consistently found in ascites, ovarian cyst fluid, and plasma samples, confirming the presence of pathogenic mutations in each sample type across all patients. This study underscores the potential of liquid biopsies in clinical molecular diagnostics. The TP53 mutation panel presented in this proof‐of‐concept study offers a promising approach for differential diagnostics and detection of HGSC, informative data prior to extended investigation and first‐line treatment guidance.