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Chapter 3: Cofactors in Human Papillomavirus

Carcinogenesis—Role of Parity, Oral Contraceptives, and
Tobacco Smoking
Xavier Castellsague´, Nubia Mun˜oz

INTRODUCTION
It is now well established that infection with oncogenic human papillomavirus (HPV) types is the necessary cause of cervical cancer (CC) and its immediate precursor cervical intraepithelial neoplasia (CIN) 3 (CIN3). However, HPV infection
alone may not be sufficient to cause CC, and other exogenous or
endogenous factors might exist that, in conjunction with HPV,
influence the risk of progression from cervical HPV infection
to CC.
Candidate cofactors may be classified into three groups: 1)
environmental or exogenous cofactors, including use of oral
contraceptives (OCs), tobacco smoking, diet, cervical trauma,
and coinfection with human immunodeficiency virus (HIV) and
other sexually transmitted agents; 2) viral cofactors, such as
infection by specific types, coinfection with other types, HPV
variants, viral load, and viral integration; and 3) host cofactors,
including endogenous hormones, genetic factors such as human
20

leukocyte antigen, and other host factors related to the host’s
immune response.
The purpose of this chapter is to review, summarize, and
discuss the evidence of the role of the more established cofactors, including parity, OC use, and tobacco smoking.
Cofactors involved in the natural history of HPV infection are
reviewed in Chapter 2. In this chapter, the focus is on cofactors
affecting progression from HPV infection to high-grade squamous intraepithelial lesions (HSILs) and CC. Ideally, if we accept the premise that all CCs are caused by oncogenic HPVs, a
strict assessment of cofactors requires a study group known to be
exposed to HPV. From that HPV-exposed group, retrospectively
or ideally prospectively, the added risk attributable to other factors can be estimated. Although this approach is admittedly controversial (see the “Discussion” section), we believe that, in the
absence of repeated HPV measures, restriction to HPV DNApositive case patients and control subjects conveys the strictest
approach to adjustment for HPV. This review will thus focus on
selected key studies that, using reliable DNA-detection methods,
report associations between cofactors and HSIL/CC within a
well-defined HPV-positive group. These studies do exist and the
main characteristics of the most important ones are summarized
in Table 1 [(1–9); Plummer M, Herrero R, Franceschi S, Meijer
CJ, Snijders P, Bosch FX, et al.: unpublished data]. Studies
among HPV-positive women that included low-grade squamous
intraepithelial lesions (LSILs) (10) or the three grades of CIN
(11) are not considered in detail in this chapter.

EVIDENCE FOR A ROLE
CARCINOGENESIS

OF

OC

USE IN

HPV

Use of OCs has been found to be associated with CC in many,
but not in all, epidemiologic studies that adjusted for HPV status. In studies restricted to HPV-positive women, however, the
evidence for an association is in general weaker (Table 2). Of the
six studies reporting results restricted to HPV DNA-positive
subjects, three found positive statistically significant associations, but these were for a particular histologic type or for a
subgroup of women. The Eastern U.S. study (3) reported an odds
ratio (OR) of 17.1 (95% confidence interval [CI] ⳱ 1.5 to 188.2)
for current versus never OC use, but this was only for adenocarcinoma in situ; although the risk increased with longer duraAffiliations of authors: X. Castellsague´, Institut Catala` d’Oncologia, Servei
d’Epidemiologia i Registre del Ca`ncer, L’Hospitalet de Llobregat, Barcelona,
Spain; N. Mun˜oz, International Agency for Research on Cancer, Lyon, France.
Correspondence to: Xavier Castellsague´, M.D., Ph.D., M.P.H., Institut Catala`
d’Oncologia, Servei d’Epidemiologia i Registre del Ca`ncer, Gran via s/n, km
2.7, 08907 L’Hospitalet de Llobregat, Barcelona, Spain (e-mail: xcastellsague@
ico.scs.es).
See “Notes” following “References.”
Journal of the National Cancer Institute Monographs No. 31, © Oxford
University Press 2003, all rights reserved.

Journal of the National Cancer Institute Monographs No. 31, 2003

Downloaded from http://jncimono.oxfordjournals.org/ by guest on November 5, 2015

It is now well established that infection with oncogenic human papillomavirus (HPV) types is the necessary cause of
cervical cancer (CC) and its immediate precursor cervical
intraepithelial neoplasia 3. However, HPV infection alone
may not be sufficient to cause CC, and other exogenous and
endogenous factors may exist that, in conjunction with HPV,
influence the risk of progression from cervical HPV infection
to CC. In this chapter, we review the evidence for the role of
parity, oral contraceptive (OC) use, and tobacco smoking in
CC. We also discuss limitations and methodologic problems
encountered in assessing available data and outline recommendations for future research. Based on key studies on
high-grade squamous intraepithelial lesions (HSILs) and CC
conducted among HPV-positive women, it can be concluded
that high parity, smoking, and less consistently long-term
OC use are cofactors that may modulate the risk of progression from HPV infection to HSIL/CC. From a public health
point of view, parity seems to be the behavioral cofactor
explaining the highest proportion of CC cases among HPVinfected women. Smoking and long-term OC use may have a
similar impact in populations that are heavily exposed to
HPV and to these cofactors. Large prospective and retrospective cohort studies of HSIL and CC among middle-aged
women in which several markers of HPV exposure are used
and HPV persistence is documented would be valuable to
study the role of these and other cofactors in HPV carcinogenesis. If confirmed, our conclusions may imply that multiparous women, women who are smokers, and women on
long-term OC use may need closer surveillance for cytologic
abnormalities and HPV infections than women in the general population. [J Natl Cancer Inst Monogr 2003;31:20–8]

2002 (8).1) NR NR NR NR Duration estimates computed among women with <3 pregnancies Relative risk refers to current vs.6 to 1.K.12 ORs not reported For adenocarcinoma in situ Manchester. 1999 (3).5) 17.6 to 2. OC ⳱ oral contraceptive. 2001 (6) Castle et al.8 to 2. HSIL ⳱ high-grade squamous intraepithelial lesion. 2000 (5) Hildesheim et al. 2002 Case–control.4 to 27. ‡HPV16 only. smoking Parity. OR (CIN3 and CC) IARC (CIS and CC) NR 1. Thailand..oxfordjournals.5) [>8] 1. CIN ⳱ cervical intraepithelial neoplasia. the trend was of borderline statistical significance. never NR NR NR OC use duration [Years] OR (95% CI) vs.3) with increasing [−6] 4.7 to 2.4 to 1.4) 3.1 to 9.2) Decreasing risk [−2] 4.1-fold increased risk for users of 5 or more years as compared with never users.7 to 52.4 (0. OC use. never Current vs.K.9) [−4] 1. OC use. 2001 (4) Deacon et al.7 (0.5 to 1.5) 1. 2002 (7) Design Case–control within cohort Population HSIL 71/79 Case–control Case–control Population CIN2 and CIN3 60/90‡ Population CIS and CC 263§ Case–control within cohort Population CIN3 199 Case–control within cohort Population HSIL and CC 146/168㛳 Prospective cohort Health plan CIN3 and CC 155/994 14/216‡ 49/307 181 843㛳 Cohort of 1812 women positive for oncogenic HPV DNA GP5+/6+ L1 PCR MY09/MY11 MY09/MY11 PCR Hybrid Capture 2 Parity.6) 1. Colombia.8 (0.2) [−9] 2.Table 1.9 (0.. Eastern (CIS and CC) 5.. PCR ⳱ polymerase chain reaction. 2003 21 Downloaded from http://jncimono. and tobacco smoking in cervical carcinogenesis among HPV DNA-positive women* Study Study characteristics Denmark United States. U. (CIN3) Costa Rica (HSIL and CC) United States.8 (1.9) [艌5] 3.5 (0. 㛳High-risk genotypes only.4 to 44.) Kruger-Kjaer et al.5 to 5. and Paraguay.2 (0.8 (0. CI ⳱ confidence interval..0 to 2. OR (95% CI) Ever vs.4 to 1. 31. 1998 (1) Olsen et al.5) NR 0. smoking *CC ⳱ cervical cancer.org/ by guest on November 5. OC use.. tion of use. 2015 Source of subjects Outcome HPV-positive case subjects/ total tested HPV-positive control subjects/total tested HPV DNA detection Relevant cofactors assessed¶ IARC. HPV ⳱ human papillomavirus. IARC ⳱ International Agency for Research on Cancer. Moreno et al. §All case subjects were included regardless of HPV status. OC use. 1998 (2) Lacey et al. †Includes studies in Spain.1 (0. Even though ever use of OCs was moderately associated with cancer risk (OR ⳱ 1.1 to 7. United States Portland.2 (0. Characteristics of studies assessing the role of parity.4) [艌10] 4. y.5 to 1. CIN ⳱ cervical intraepithelial neoplasia. Journal of the National Cancer Institute Monographs No. The Philippines. (reference No. Brazil.001 [−3] 1.0 (2. OC use.2 (0. smoking Parity..4 to 51.5 (0.4 (1..† international .0) NR NR [1] 0. unpublished data. OR ⳱ odds ratio. OC use.0 (0. there was a strong dose–response Table 2.5 to 188.1 (1. NR ⳱ not reported. IARC ⳱ International Agency for Research on Cancer. smoking Smoking Smoking.8) NR NR 0.4) [−8] 0.8 (0. but this association was observed only among women who had two or fewer pregnancies.3 (0.9) duration [艌7] 6.. The strongest evidence for a role of OC use in HPV carcinogenesis derives from the large pooled analysis of the International Agency for Research on Cancer (IARC) studies (9).1) 1..7 to 43. Plummer et al. 2002 (9). HSIL ⳱ high-grade squamous intraepithelial lesion. OR Costa Rica Authors. CIS ⳱ carcinoma in situ. Bold numbers denote statistical significance. never P for trend Comments United States. and the HSIL/cancer group included only 30 cases. OC ⳱ oral contraceptive.1 (1. not current OC use at enrollment For both squamous cell carcinoma and adenocarcinoma *Numbers are odds ratios (or relative risks) and 95% confidence intervals for the association between the corresponding exposure measure and HSIL/CC risk.1) [−4] 0. **For adenocarcinoma in situ. Summary results of studies assessing the role of OC use as a cofactor in cervical carcinogenesis among HPV DNA-positive women* Study (study outcome) Exposure measures Denmark (HSIL) OC use status. CC ⳱ cervical cancer. ⲆFor squamous cell.6 to 4. U.Ⲇ OC use** Parity. Peru.8 (0. smoking Mun˜oz et al. never Former vs.7) NR .8 to 2.8 (0.8) <. Morocco.4). HPV ⳱ human papillomavirus. CIS ⳱ carcinoma in situ. ¶Cofactors in bold type indicate that a statistically significant association was found for that cofactor. Eastern Norway Manchester. pooled analysis Clinic and population CIS and CC 1676/1853 255/1916 MY09/MY11 and GP5+/6+ Parity. The study in Costa Rica (6) found a 3.6 to 2. Portland.

Alternatively. this result could be explained by the low parity of the study populations.6 (0. (HSIL and CC) 4. thus potentially missing an association with long-term use.e.8 (0. hormonal.9) [5–6] 2.org/ by guest on November 5.4. Finally. OR (CIN3 and CC) IARC (CIS and CC) NR NR [1–2] 1. Special attention should be given to the lack of association reported in the only prospective study of CIN3 and CC (7).5). prospective study (7) did not find an association with the risk of HSIL and CIN3/CC.4 to 5.8) [2] 1.6 to 3. Second.7) [艌1] 1. No increase in the risk of cervical neoplasia was found for the duration of OC use for up to 4 years. U. further evidence of a hormonal effect on CC comes from the analysis of the age-distribution curve based on cohort effects in relation to mortality without the distortion potentially introduced by screening and secular changes.7 to 3. IARC ⳱ International Agency for Research on Cancer.K.04 United States. However.oxfordjournals. and immunologic mechanisms have been hypothesized as biologically plausible explanations for the association between parity and HSIL/CC among Table 3. In addition. 31. HSIL ⳱ high-grade squamous intraepithelial lesion.5). CIS ⳱ carcinoma in situ. which results in deregulation of E6 and E7 expression (12).0 to 5.0001 For both CC and CIS *Numbers are odds ratio (or relative risks) and 95% confidence intervals for the association between the corresponding exposure measure and HSIL/CC risk.8) NR NS Unadjusted Costa Rica. The analysis shows that CC mortality rates increase very sharply up to age 50 years (i.2)§ [3] 1. The risk of OC use for longer than 5 years was increased fourfold for invasive CC (OR ⳱ 4. traumatic. NS ⳱ not significant. EVIDENCE FOR A ROLE CARCINOGENESIS OF PARITY IN HPV High parity has consistently been found in most case–control studies to be associated with both CC and CIS. §Reference includes women with 0 or 1 live birth.S.9 to 2. As the same authors discuss. first. never P for trend Comments Denmark (HSIL) Manchester.1 to 5. OCs might facilitate HPV reactivation or persistence. Since the E6 and E7 open reading frames have been associated with the oncogenic potential of HPV16.6 (1. A borderline association with CIN3 was found in the Manchester study (5).4..9) NR <. However.S. thus not accounting for the possible discontinuation or initiation of use of OCs during the course of the study. OC users had shorter follow-up times than nonusers.8 (1. only one measurement of OC use was obtained at enrollment. 95% CI ⳱ 2.] OR (95% CI) vs.3 to 1.5) [3–4] 2.6 to 1.0 (0.9 (1.5 (0.9 (1.6 to 2. around menopause) and flatten thereafter.0) and threefold for carcinoma in situ (CIS) (OR ⳱ 3.5 to 2. Thus. Hormonerelated mechanisms may influence the progression from premalignant to malignant cervical lesions by promoting integration of HPV DNA into the host genome. respectively. no information regarding duration was collected.0)§ [艌9] 1. use of OCs for longer than 5 years was significantly associated with cervical neoplasia (OR ⳱ 3.0 to 3.0 to 8.6) [艌7] 3.1 to 20)† [2] 1.2 (1. In the IARC-pooled analysis. never. the OR for CC in women with seven or more full-term pregnancies was fourfold higher than that in nulliparous women. among the control subjects.4)§ . ‡Ever pregnant but 0 live births. In addition to the studies restricted to HPV-positive women.HPV16-expressing mice.6 (1. Most of the major studies restricting the analysis to HPV-positive women also report an increased risk of HSIL/CC with an increasing number of pregnancies (Table 3).6) [1–2] 1. Third. although indirect evidence from several studies (9. the effect of estrogen on the transcription of these viral genes may be of biologic relevance in the malignant transformation of HPV16infected cervical cells. Summary results of studies assessing the role of parity/pregnancy in cervical carcinogenesis among HPV DNA-positive women* Study (study outcome) Exposure measures Ever vs. 2015 relationship with increasing years of use (Table 2). 2003 Downloaded from http://jncimono.4 (0. OR (95% CI) No. Data from experimental studies (14. pregnancies occurring during the 10-year follow-up period of the study might have been more relevant to the prospective risk of CIN3/CC than those occurring before enrollment.8 (0. Portland.2)§ [4–5] 3.1 (0.3) [1] 1. HPV ⳱ human papillomavirus.15) demonstrate a synergistic mechanism between long-term estrogen exposure and HPV16 oncogenes that modulates squamous carcinogenesis in the female reproductive tract of transgenic .7 (0. see review in 16) does not find an association between OC use and HPV positivity among control women. cohort.9 (0. Risk of HSIL/CC significantly increased with an increasing number of live births in the Costa Rica study (6). which may have resulted in an increased detection and treatment of women in the control group whose disease might have otherwise progressed to CIN3 or CC. CIN ⳱ cervical intraepithelial neoplasia. in the U. †OR for ever versus never pregnant. CI ⳱ confidence interval. An experimental study (13) has shown that estradiol may stimulate the transcription of HPV type 16 (HPV16) E6 and E7 in cell lines that contain integrated HPV16. of live births or pregnancies [No. which may have resulted in censoring bias among the users.2)§ [6–8] 2. Nutritional.4 to 1.7) [艌3] 0.0) [艌3] 1.3 to 2. OC users were more likely to be diagnosed with CIN1 and CIN2 during follow-up than nonusers. Bold numbers denote statistical significance. CC ⳱ cervical cancer. and the risk increased linearly with an increasing number of fullterm pregnancies (8). 22 Journal of the National Cancer Institute Monographs No.1 to 5.9 to 3.0.5 (1. The study in Denmark (1) and the U. 95% CI ⳱ 2. information on parity was recruited only at enrollment.9 to 7. Not much data are available concerning the mechanisms by which hormonal influences may modulate the risk of progression to HSIL/CC among HPV-infected women.7 to 7.3 to 4. NR ⳱ not reported. 95% CI ⳱ 2.1 (0. (CIN3) NR NR [0]‡ 0. OR ⳱ odds ratio.

2 to 4. U. High parity may likely increase the risk of CC because it maintains the transformation zone on the exocervix for many years (17).2 (1. Eastern (CIS and CC) Denmark (HSIL) NR [−9] 2. AND CC COFACTOR PROFILES Finally.5 (1.0 to 3.K. even after adjusting for the strong effects of HPV. As shown in Table 4. most studies reporting risk estimates according to intensity.3 to 2.3 (0. duration. residual confound- ing by time since HPV infection cannot be ruled out as a possible explanation for the observed effects of smoking.9 to 11. Hormonal changes induced by pregnancy (increased levels of estrogen and progesterone) may also modulate the immune response to HPV and influence risk of persistence or progression (8. since it has been shown that smoking may reduce the number of Langerhans’ cells and other markers of immune function. or pack-years show an increased risk of CC with increasing exposure to tobacco smoking.8 (0.9 to 3. NR ⳱ not reported.9) 4.8 to 5.6 to 3.3 (1.infected women.4) 1.8 (0. CIS ⳱ carcinoma in situ.9 (1. Furthermore.9 (1.9) NR 2.9) [艌17] 3.0) 1.5) NS Univariate OR.7 to 3. EVIDENCE FOR A ROLE HPV CARCINOGENESIS OF TOBACCO SMOKING IN EVIDENCE FROM STUDIES COMPARING LSIL.7) [−19] 2.5 to 5.2 (0. possibly.2) 1. malignant transformation of HPV16immortalized human endocervical cells by cigarette smoke condensate has been proven (20).0) 2.3 (1.5 (0. Bold numbers denote statistical significance. The fact that nicotine and tobaccospecific carcinogens have been detected in the cervical mucus of smokers (21) further strengthens the hypothesis of a synergistic action between cigarette smoking and HPV for the development of HSIL/CC. Rous and Friedwald (19) reported the carcinogenic effect of tar on virus-induced rabbit papillomas. the possibility remains that smoking or smoking duration is a proxy for time since HPV exposure.2) [艌6] 3. never P for trend Smoking duration [years] OR (95% CI) vs. hormonal influences can be considered to be one of the most promising candidates in the search for HPV cofactors.4 to 3.2 to 4. More recently. the positive association found with smoking status and smoking intensity in the U.7 to 3.7) [艌20] 1.4) [艌6] 2.0005 NR For squamous cell carcinoma [−5] 1. (CIN3) Costa Rica (HSIL and CC) United States Portland.2 to 46) NR Stronger associations found among HPV16seropositive subjects .2 (1. Some authors (22) hypothesize that exposure to tobacco may affect the ability of the host to mount an effective local immune response against viral infections. never Former vs. prospective study is particularly relevant (7).3) [−19] 2.0 to 9.org/ by guest on November 5.3 to 4.8) [−20] 3.7 to 2.0) Exposure measures Smoking status.9 (1.9 to 22.5 to 21) [艌11] 5. OR ⳱ odds ratio.3) <.6 (1.3) NR 2. Summary results of studies assessing the role of cigarette smoking in cervical carcinogenesis among HPV DNA-positive women* Study (study outcome) Manchester.7 (0.oxfordjournals. HSIL ⳱ high-grade squamous intraepithelial lesion.003 [−10] 1. The significant association found between the extent of smoking reduction and the reduction in lesion size in an intervention study of smoking cessation among women with minor-grade lesions further strengthens the plausible role of tobacco smoking in HPV carcinogenesis (24).0 (1. because of the concordance of effects with OC use.0) [−10] 1.1 (1. Journal of the National Cancer Institute Monographs No.2 to 3.8 (1.2 (0.3) [艌10] 2.2) NR NS NR [−19] 2. Thus.1 (1.2 (1. it is worth mentioning that few cofactors have been identified to distinguish invasive cancer from intraepithelial lesions or HSIL from LSIL.0 to 4. Almost 60 years ago.57 <. .3) [艌10] 7.8 (0. The ORs for ever smoking among HPV-positive women are in the range of 2 to 5. however. OR (CIN3 and CC) IARC (CIS and CC) NR 1. never Current vs.9) [艌20] 1.7) NR NR [−10] 3.2 to 7. all such studies report some evidence that tobacco smoking increases the risk of developing HSIL and CC.5 to 37.0001 Smoking amount [cigarettes/day] OR (95% CI) vs. because long-duration smokers may also have had an HPV infection for a long time. 2015 The effects of smoking have been well studied in many case– control studies. OR (95% CI) Ever vs. A recent prospective study (23) presents convincing evidence that smokers maintain cervical HPV infections significantly longer and have a lower probability of clearing an oncogenic infection than women who never smoked.2) .2 to 4. Chemical tobacco-related carcinogens may exert a direct mitogenic effect causing DNA damage.4 to 4.6 (0.0 to 3. to other cofactors.6) . 31.2 (1. HPV ⳱ human papillomavirus. NS ⳱ not significant.0 to 3.5 to 3. Because of the prospective nature of the study.9) [艌20] 2. CIN ⳱ cervical intraepithelial neoplasia.8 to 3. 2003 23 Downloaded from http://jncimono. never NR 3. These findings are strikingly consistent with those obtained in studies restricted to HPV-positive women.6) [−9] 2.8) [>20] 0.2 (0. facilitating the direct exposure to HPV and. CI ⳱ confidence interval.6 to 6.S.3 to 12. The IARC Spain–Colombia study Table 4.2 (0.4 (0. Despite the consistency of these findings.6 to 3.0 to 3.0) [−9] 1.4) 2.1 to 3.1 (0.18).5) 2.1 (1. CC ⳱ cervical cancer.5 to 3. Adjusted OR also statistically significant *Numbers are odds ratios (or relative risks) and 95% confidence intervals for the association between the corresponding exposure measure and HSIL/CC risk.8) 4.1 to 3.2 (1. and they show a moderate and statistically significant association with CC.1) 1.7) [艌20] 3.3 (0. never P for trend Comments NR NR NR Norway (CIN2 and CIN3) United States.2 (1.7 (0.9) NR 1.8 to 4.5) [−16] 2. HSIL.4) 1.6 (0.2 (1.0 to 36) [−19] 1.5 to 3.0 (1.9 (1.6 (0.49 [−5] 1. IARC ⳱ International Agency for Research on Cancer.2 to 3.1 (1.9 (1.9 to 3.

we were able to estimate the impact of different strategies of HPV adjustment on associations between environmental cofactors and CC risk. A recent study (26) conducted in Thailand found that.(25) considered a large number of risk factors and found that both the CIN3 and CC patients had very similar profiles of risk factors. In these studies. we focused on factors that. of serologic markers of HPV infection. we fitted three different models: 1) one model including all case patients and all control subjects but ignoring adjustment for HPV. DISCUSSION Methodologic Issues in the Study of Cofactors in HPV Carcinogenesis 24 Journal of the National Cancer Institute Monographs No. These cofactors can be identified by cohort or case–control studies of HPV-positive women in which case patients include those diagnosed with HSIL. Estimation of attributable fractions of CC explained by the various cofactors. If it is claimed that this method of adjustment is better than the other strategies in getting rid of residual confounding. To assess the overall impact of cofactors on CC burden. because some have LSIL.0-fold higher than those derived from HPV-adjusted models. Studies aimed at identifying factors for HPV acquisition and persistence were considered in Chapter 2. under the premise that HPV is a necessary cause of CC. Here. and 3) a third restricting the analysis to case patients and control subjects who tested positive for HPV DNA. models restricted to HPV DNA-positive subjects yielded higher associations that were between 1. regardless of the strategy used. 2003 Downloaded from http://jncimono. after controlling for HPV type. 2) a second including all subjects but adjusting for HPV DNA status. an alternative approach is to explore the use.e. 31. Again. Beyond the discussion of which adjustment method is more suitable in the assessment of cofactor. as compared with the risk of developing intraepithelial lesions. were intermediate for the HPV-adjusted models. acting once HPV infection has been established. a marker of HPV exposure more than a disease outcome.org/ by guest on November 5. then we should expect lower rather than higher ORs. . In other words. or CC but not those diagnosed with LSIL or CIN1. if most HPV infections in middle-aged women tend to be persistent. Perhaps negative confounding between cofactors and HPV status or selection bias introduced by restricting the analysis to HPV-positive subjects (i. it is reassuring to observe that. of the three strategies. the risk of developing CC.1. The nested case–control studies carried out in Denmark (1) and in the United Kingdom (5) suggest that the pattern of risk factors for HPV infection or LSIL are different from the patterns for CIN3 and HSIL. Use of HPV DNA detection alone may overlook past infections that being clinically relevant at the time were cleared from the cervix. depending on the assay and on the number of types included) might pose problems of selection bias (i. the magnitudes of the ORs were lowest for the crude models. to have smoked. clearly an HPV-related disease outcome. the same conclusions concerning the direction and statistical significance of the associations are reached. modulate the risk of progression from HPV infection to HSIL/CC. However. women who did not trigger a detectable seroconversion after a relevant HPV infection would not be selected by the serologic assay). or to have used OCs for a long time. Which assay or combination of assays is best suited to select HPV-exposed or HPV-positive women still remains an important research issue for which more data are needed.oxfordjournals. some have also included women with LSIL in the HPV-positive control group (6). the definition of HPV-positive control women based on a single mea- sure (used in most studies) might not be sufficient. Furthermore. the HPV-adjusted models yielded lower ORs than the crude and HPV-restricted models. the case–control matching is totally ignored after restriction) might explain the increase in the ORs. and some have HSIL/CC.. its low sensitivity (between 50% and 70%. Accepting that HPV is a necessary cause of CC. Using the IARC series of case– control studies. As shown in Table 5. case patients and control subjects can be defined on the basis of HPV/LSIL status. we found that it is useful to estimate the percentage of disease that can be attributed to each cofactor. while HPV serology is highly specific. However. For parity and smoking. the use of a single HPV test may be more of a problem in studies of HSIL than in studies of invasive CC. a more refined case definition could be made on the basis of both HPV and disease statuses. and 3) by increasing the risk of progression from HPV infection to HSIL and cancer. except for two indices of socioeconomic status. Younger women are less likely to have had a high number of pregnancies. alone or in combination with HPV DNA detection. It remains to be explained why we see stronger rather than weaker effects when analyses are restricted to HPV-positive case patients and control subjects. can we assume that crosssectionally identified HPV-positive control women are carrying a persistent or chronic infection? How long should persistent infection persist to increase the risk of CC: many months or just a few months as suggested recently (28)? If persistent infections are associated with CC risk. If we believe that HPV restriction is the strictest approach to HPV adjustment. CIN3. In contrast. 2015 Definition of case patients and control subjects. Studies (11) including the whole spectrum of precancerous lesions as cases are difficult to interpret because the case group includes a mixture of exposed and diseased women. Because many investigators consider LSIL an early manifestation of HPV infection. one could then conclude that the studies adjusting for HPV are likely to underestimate the magnitude of the association but that this underestimation is not greater than twofold. was not related to any of the cofactors considered. suggesting that HPV-infected cells may relate to tobacco-containing carcinogens for neoplastic progression. HPV adjustment strategies.e. HPV cofactors in CC may act in at least three ways: 1) by influencing the acquisition of HPV infection. and were highest for the HPVrestricted models. the interpretation of results from studies including young women (most of the HSIL studies in Table 1) is further limited by the fact that measures of the putative environmental cofactors are strongly age dependent. In relation to the control subjects and the selection of HPVexposed women. a study comparing HPV-positive women with CIN3 with HPV-positive women with CIN1 (27) found that cigarette smoking was significantly associated with CIN3. For OC use. 2) by increasing the risk of HPV persistence. we believe that proper control subjects for these studies ought to be HPV-positive women. Since the goal in the assessment of cofactors is to explore associations among HPV-exposed women. CIS. For each of the three cofactors of interest.and 2. In contrast. the key issue is whether one-point HPV positivity can be considered to be a sufficient criterion to define the proper control group..

Epidemiologists should encourage their laboratory colleagues to carry out experimental studies on this issue. 31.35 (1. 5–6.44 to 3.11 to 1. Thus. 46–55. these conclusions should be taken only as a crude approximation to the issue because the overall disease burden attributable to the cofactor depends not only on the percentage of HPV-positive women exposed to the cofactor but also on the overall HPV prevalence in the population.56 to 2.08) 1.32 (0. CI ⳱ confidence interval. 2–3.58 to 0. this analysis suggests that multiparous HPV-positive women constitute the group at the highest risk of CC.07 (1.85) 1† 1. duration.09 (0.72 (0. IARC ⳱ International Agency for Research on Cancer. low OC use.68 (1.08 (0.75 to 1.45 to 2.16 (1. or 艌56 years). Impact of different strategies of HPV adjustment on associations between cofactors and risk of CC (from the IARC case–control studies)* All women Cofactor Full-term pregnancies (status and No. or 艌4).57) 2. these studies will be able to explore the interaction between endogenous and exogenous hormones and HPV infection in middle-aged women.51) 1. OC use (never.59) 0. Despite these limitations. However.98 to 1.97) 2. In addition.94 to 3. 2015 HPV adjusted.13 (0.03 (1. OC ⳱ oral contraceptive.55) 1† 1.68 (1.82 (0. CC ⳱ cervical cancer. the estimates reported in Table 6 or in the Costa Rica study do not take the latter parameter into account.75 (0.22) 1† 1.80 to 1. or 艌10 years). secondary.30 (1.97) 1. 1–4 years.4% of the case patients were exposed to none of the risk categories of the cofactors considered.30 to 3.09 to 2. lifetime number of sexual partners (1. OR (95% CI) 95/164 2183/2209 1–2 HPV-positive women .47) 0.97 to 1. or higher). since the use of standard methods to estimate attributable fractions (AFs) may be inadequate under a model that assumes that the exposures for which AFs are to be estimated are only relevant once the individual is or has been exposed to a necessary etiologic factor. among HPV-positive women.16) 57/24 1616/229 1† 1.17 (0.60 to 1.73 (1. smoking amount (never. or 艌7).29 to 3.59) 1† 0.92 to 1. Recommendations for Future Research On parity and hormonal factors. or 艌6 cigarettes/day).24 to 2.65 to 1. educational level (none.79 (1. 1–5. age (<37.66 (0.27) 0. or 艌23 years).88 to 1. since such studies will be valuable for bolstering (or not) the biologic plausibility of the epidemiologic associations. 1–2.50) 1. 37–45.83) 1.07) 1. given the high percentage of HPV-positive women with two or more full-term pregnancies and the relatively strong association for CC at this parity level.80 to 1. or 艌6).45 to 0.18 to 3.79 to 1.09 to 1. concentrations. HPV ⳱ human papillomavirus.99 to 7. recency. AFs are comparatively higher for parity than for the other cofactors.11 to 1. 1) Taking into account the second peak in the prevalence of HPV DNA observed in perimenopausal and postmenopausal women in some populations (29–31).00) 3.21 (0.33 (0.99 (1.52) 1. OR (95% CI) 1419/1508 864/886 1–4 y Smoking (status and amount) Never Ever Not HPV adjusted.19) 0.90 (0.) Never Ever Cases/controls 444/747 3–4 644/677 艌5 1095/785 OC use (status and years) Never Ever 1† 1.97) *ORs adjusted for center. Table 6 shows that the most prevalent combination of cofactors among case patients is that including high parity.33 to 4.36 to 2.98) 2. 3–4. OR ⳱ odds ratio. primary. †Referent.oxfordjournals. As shown in Table 6.51) 1.01) 2.99 (0. suggesting that the fraction of the case patients in whom these cofactors may not play a role is probably very low. 2003 show that only 5. and latency and to determine at which stages of 25 Downloaded from http://jncimono. and never smoking (55. age at first sexual intercourse (<17. 5–9 years.97 (0. Are the endogenous hormone levels and/or hormone replacement therapy (HRT) associated with HPV DNA detection and progression to cancer in postmenopausal women? 2) Little is known about the influence of hormones on the mechanisms of HPV carcinogenesis.46 (1.88 (1. 3) Further studies on OC use and HRT are needed to clarify their role in relation to type of hormones. 19–22.79 (0. lifetime number of Pap smears (0. We also Journal of the National Cancer Institute Monographs No. the “necessary-cause” model of HPV carcinogenesis poses a methodologic challenge.Table 5.49) 1071/163 605/92 351/445 艌5 y 510/427 1† 1. it would be of interest to conduct studies in these women and their male partners to try to distinguish if this second peak is the result of reactivation of latent infections or new infections. we (Table 6) and others (6) have estimated AFs for cofactors by using as parameters the percentages of women exposed to the cofactor of interest among HPV-positive women and the OR for CC derived from analyses restricted to infected women.09) 1. 1–5 cigarettes/day.org/ by guest on November 5.33 (1.45 (1.40) 2.94 to 1.75) 1265/218 409/36 1645/1905 636/488 1–5 cigarettes/day 251/200 艌6 cigarettes/day 350/216 Case/control 279/59 450/70 887/100 274/64 331/28 181/17 211/18 OR (95% CI) 1† 2.8%).41) 1† 1.61 (1.98) 0. and parity (0. 17–18.98 to 3.37 to 5. We also assessed the impact of different combinations of cofactors on CC burden.12) 1.

OR ⳱ odds ratio. As mentioned before. OC ⳱ oral contraceptive. Brazil. including as control subjects women with at least two consecutive HPV-positive smears over time to confirm their chronic carrier state. Second. HPV ⳱ human papillomavirus. they could be introduced alone or in combination with HPV DNA in retrospective cohort studies that stored sera and cells and prospectively monitored relevant cofactors. 0–1 艌5 vs. while allowing for the assessment of risk factors for disease progression. Alternatively. 31. One should.0 39. However.63 2.98 2.2 5. realize that the use of persistently 26 HPV-positive control subjects. These cohort studies will be able to adjust for the number of HPV infections and also be useful to determine at which stage of the carcinogenic process these cofactors act.S. and intake of exogenous hormones.8 15.6 0. lifetime number of Pap smears. As more refined serologic assays are being developed and validated. Journal of the National Cancer Institute Monographs No.70 4 16 Smoking Ever vs. it would be interesting to study the relationship between time trends of CC rates and those of OC use and smoking.4 3. the value of HPV serology as a marker of cumulative lifetime exposure needs further study. OC use (years).7 1. provide an assessment of the potential bias introduced in studies that restricted analyses to cross-sectionally detected HPV-positive control subjects. never 艌5 vs. Proportion of cervical cancer cases attributable to various HPV cofactors. probably by increasing multiple serotypes. in addition.87 4.6 89. lifetime number of sexual partners. it is evident that more epidemiologic research is needed to understand the value of serologic markers of HPV exposure in studies on cofactors. It would be valuable to study the influence of declining birthrates on declining CC rates. age at first sexual intercourse.2 7. Except for the U.8 53. Thus. never 艌2 vs.0 2.2 8.4 63. cohort study (7). 0–1 90. and analyze the new data stratifying by HPV-persistence status. The selection of proper control subjects depends on the basic assumption that most HPV infections in older women are persistent.8 0.7 55. Finally. These issues will be better studied in cohort studies of premenopausal and postmenopausal women than in case–control studies. Studies comparing the natural history of HPV infections with the dynamics and patterns of seroconversion are needed to better understand the meaning of these markers and to comprehend why some women experience seroconversion and some do not. the conduct of large case–control studies. 1 ⳱ referent category. This strategy would. retest them for cervical HPV DNA. y .51 3.1 11. especially in those countries where screening programs do not exist or have had little impact. unpublished results from a follow-up study of control women included in our case–control studies in Spain and Colombia suggest that this may not be the case.27 58 34 33 OC use Ever vs.13 2.0 36.1 19.08 12 7 Combination of cofactors Parity Smoking % among control subjects % among case subjects OR† AF. Similarly.5 83.org/ by guest on November 5.7 4. never 艌6 cigarettes/day vs. would limit the ability of evaluating factors potentially associated with viral persistence itself. however. These studies will be of great value in establishing if the effects of cofactors that we are detecting in case– control studies are real or.5 0. prospective studies of middle-aged HPV-positive women are needed to assess this assumption and to better understand the natural history of HPV infections in older women. The first pending issue is to improve the sensitivity of current serologic assays of HPV infection. age. 2003 Downloaded from http://jncimono. on the contrary.Table 6. no prospective data on cofactors are yet available from the large cohort studies being conducted in Costa Rica.6 0.7 1.4 3. would circumvent some of the limitations currently encountered in the interpretation of results from previous studies. Correlation analyses of time trends. 0 cigarettes/day 14.02 — 4 1 1 28 15 22 11 *AF ⳱ attributable fraction. it would be important to undertake studies making measurements of markers of local immunity and inflammation and correlating them with other cofactors. such as pregnancy.4 12. †Adjusted for center.61 2.51 1. 0–4 36.and HPV antibody-detection methods are needed to contrast our current DNA-based risk estimates linked to the different cofactors and to assess whether the combination of both assays could improve unbiased selection of exposed women.8 1 2.7 9. and Colombia. Other studies.5 96. Choice of proper control subjects.12 2.16 11. Assessment of unpublished results from these cohort studies would be informative in the planning of further research strategies on this issue. 4) Also. smoking amount. % Full-term pregnancies Ever vs.oxfordjournals. separately or in combination* Separately HPV cofactor Level of exposure % among control subjects % among case subjects OR† AF.5 13. and parity.1 24. age. carcinogenesis they may act. 2015 0–1 0–1 0–1 0–1 艌2 艌2 艌2 艌2 OC use. studies using both HPV DNA. A quick approximation to this approach for recently completed studies would be to recontact HPV-positive control women. merely due to residual confounding. % 0–4 0–4 艌5 艌5 0–4 0–4 艌5 艌5 Never Ever Never Ever Never Ever Never Ever 12. educational level.60 1.8 1.

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(11) Schiffman MH. Steele SJ. and long-term OC use are cofactors that may modulate the risk of progression from HPV infection or LSIL to HSIL and CC. (13) Mitrani-Rosenbaum S. A prospective study of high-grade cervical neoplasia risk among human papillomavirus-infected women. Shiboski S. From a public health point of view. (3) Lacey JV Jr. Turek L. Role of parity and human papillomavirus in cervical cancer: the IARC multicentric case–control study. et al. (9) Moreno V. Bratti MC. Cancer Res 2000. and women on long-term OC use may need closer surveillance for cytologic abnormalities and HPV infections than women in the general population. 64. Arbeit JM. Pater A. Different risk factor patterns for high-grade and low-grade intraepithelial lesions on the cervix among HPV-positive and HPVnegative young women.No published data are available on the analysis of cofactors by main HPV types (16 and 18) or their phylogenetic groups. 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