Socio-Demographic and Behavioural Risk Factors for Cervical Cancer and Knowledge, Attitude and Practice in Rural and Urban Areas of North Bengal, India

The E6 protein encoded by the oncogenic human papillomavirus types 16 and 18 is one of two viral products expressed in HPV-associated cancers. E6 is an oncoprotein which cooperates with E7 to immortalize primary human keratinocytes. Insight into the mechanism by which E6 functions in oncogenesis is provided by the observation that the E6 protein encoded by HPV-16 and HPV-18 can complex the wild-type p53 protein in vitro. Wild-type p53 gene has tumor suppressor properties, and is a target for several of the oncoproteins encoded by DNA tumor viruses. In this study we demonstrate that the E6 proteins of the oncogenic HPVs that bind p53 stimulate the degradation of p53. The E6-promoted degradation of p53 is ATP dependent and involves the ubiquitin-dependent protease system. Selective degradation of cellular proteins such as p53 with negative regulatory functions provides a novel mechanism of action for dominant-acting oncoproteins.

Cervical cancer is the most common cancer in women in Mali and the second commonest cause of cancer mortality. As part of an international effort to evaluate the role of human papillomavirus (HPV) in the aetiology of cervical cancer, we conducted a hospital-based case-control study in three medical centres in Bamako during 1994-1995. A total of 82 cases (invasive cervical cancer patients) and 97 controls matched to the cases for age were included. Information on risk factors was collected through personal interview. Serum antibodies to HPV 16, 18 and 31 virus like particles (VLP) were detected using ELISA assays. Polymerase chain reaction was used to detect HPV DNA in frozen biopsies of cases. Human papillomavirus 6, 18, 31 VLP were detected in 60.4% of cases and 45.4% of controls (P = 0.03). Overall, HPV DNA was identified in 96.9% of the cervical cancer cases. Risk factors for cervical cancer were parity >10 versus <5 children ([odds ratio] OR = 4.8, 95% CI : 1.5-14.7), never having practised vaginal douching (OR = 17.6, 95% CI : 4.2-74.7), re-using home-made feminine napkins (OR = 45.9, 95% CI : 8.8-238.7) and having a husband with more than two wives (OR = 5.3, 95% CI : 1.3-21.3). These data provide further evidence on the role of HPV in cervical cancer and show that high parity and poor genital hygiene conditions were the main co-factors for cervical cancer in this population with prevalent HPV infection.

A wealth of evidence has led to the conclusion that virtually all cases of cervical cancer are attributable to persistent infection by a subset of human papillomavirus (HPV) types, especially HPV type 16 (HPV-16) and HPV-18. These HPV types also cause a proportion of other cancers, including vulvar, vaginal, anal, penile, and oropharyngeal cancers. Although cervical cancer screening, primarily with the Papanicolaou (Pap) smear, has reduced the incidence of this cancer in industrialized countries, cervical cancer remains the second most common cause of death from cancer in women worldwide, because the developing world has lacked the resources for widespread, high-quality screening. In addition to advances in Pap smear technology, the identification of HPV as the etiologic agent has produced 2 recent advances that may have a major impact on approaches to reduce the incidence of this disease. The first is the development of a preventive vaccine, the current versions of which appear to prevent close to 100% of persistent genital infection and disease caused by HPV-16 and HPV-18; future second-generation vaccines may be able to protect against oncogenic infections by a broader array of HPV types. The second is the incorporation of HPV testing into screening programs. In women aged >30 years, HPV testing can identify high-grade cervical intraepithelial neoplasia earlier than Pap smears with acceptable rates of specificity. These results, together with the high sensitivity of HPV testing, suggest that such testing could permit increased intervals for screening. An inexpensive HPV test in development, if successful, may be incorporated as part of an economically viable 'screen-and-treat' approach in the developing world. The manner in which vaccination and screening programs are integrated will need to be considered carefully so that they are efficient in reducing the overall incidence of cervical cancer.