Osteoporosis identification among previously undiagnosed individuals with vertebral fractures.

Because osteoporosis is under-recognized in patients with vertebral fractures, we evaluated characteristics associated with osteoporosis identification. Most patients with vertebral fractures did not receive evaluation or treatment for osteoporosis. Black, younger, and male participants were particularly unlikely to have had recognized osteoporosis, which could increase their risk of negative outcomes. INTRODUCTION: Vertebral fractures may be identified on imaging but fail to prompt evaluation for osteoporosis. Our objective was to evaluate characteristics associated with clinical osteoporosis recognition in patients who had vertebral fractures detected on their thoracolumbar spine imaging reports. METHODS: We prospectively identified individuals who received imaging of the lower spine at primary care clinics in 4 large healthcare systems who were eligible for osteoporosis screening and lacked indications of osteoporosis diagnoses or treatments in the prior year. We evaluated characteristics of participants with identified vertebral fractures that were associated with recognition of osteoporosis (diagnosis code in the health record; receipt of bone mineral density scans; and/or prescriptions for anti-osteoporotic medications). We used mixed models to estimate adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS: A total of 114,005 participants (47% female; mean age 65 (interquartile range: 57-72) years) were evaluated. Of the 8579 (7%) participants with vertebral fractures identified, 3784 (44%) had recognition of osteoporosis within the subsequent year. In adjusted regressions, Black participants (OR (95% CI): 0.74 (0.57, 0.97)), younger participants (age 50-60: 0.48 (0.42, 0.54); age 61-64: 0.70 (0.60, 0.81)), and males (0.39 (0.35, 0.43)) were less likely to have recognized osteoporosis compared to white participants, adults aged 65 + years, or females. CONCLUSION: Individuals with identified vertebral fractures commonly did not have recognition of osteoporosis within a year, particularly those who were younger, Black, or male. Providers and healthcare systems should consider efforts to improve evaluation of osteoporosis in patients with vertebral fractures.

The persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with chronic pain.

There is uncertainty regarding how long the effects of acupuncture treatment persist after a course of treatment. We aimed to determine the trajectory of pain scores over time after acupuncture, using a large individual patient data set from high-quality randomized trials of acupuncture for chronic pain. The available individual patient data set included 29 trials and 17,922 patients. The chronic pain conditions included musculoskeletal pain (low back, neck, and shoulder), osteoarthritis of the knee, and headache/migraine. We used meta-analytic techniques to determine the trajectory of posttreatment pain scores. Data on longer term follow-up were available for 20 trials, including 6376 patients. In trials comparing acupuncture to no acupuncture control (wait-list, usual care, etc), effect sizes diminished by a nonsignificant 0.011 SD per 3 months (95% confidence interval: -0.014 to 0.037, P = 0.4) after treatment ended. The central estimate suggests that approximately 90% of the benefit of acupuncture relative to controls would be sustained at 12 months. For trials comparing acupuncture to sham, we observed a reduction in effect size of 0.025 SD per 3 months (95% confidence interval: 0.000-0.050, P = 0.050), suggesting approximately a 50% diminution at 12 months. The effects of a course of acupuncture treatment for patients with chronic pain do not seem to decrease importantly over 12 months. Patients can generally be reassured that treatment effects persist. Studies of the cost-effectiveness of acupuncture should take our findings into account when considering the time horizon of acupuncture effects. Further research should measure longer term outcomes of acupuncture.

Is acupuncture a risk factor for hepatitis? Systematic review of epidemiological studies.

OBJECTIVE: Acupuncture has been repeatedly associated with infectious hepatitis. The aim of the present systematic review was therefore to critically evaluate such data from epidemiological investigations. METHODS: Four independent literature searches were carried out to identify all epidemiological evidence linking acupuncture with hepatitis. All studies were validated by the authors and data extracted according to predefined criteria. RESULTS: Fifteen investigations fulfilled our inclusion criteria. Most studies originated from Asia. One study included markers to hepatitis A virus, three to hepatitis B virus, and 13 to hepatitis C virus. Five investigations reported associations between acupuncture and seropositivity to hepatitis C virus. In those studies, acupuncture increased the risk only modestly. CONCLUSION: A modest association between hepatitis C and acupuncture has been reported in some countries. This emphasizes the importance of exclusively using disposable acupuncture needles.

Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects.

STUDY DESIGN: A subanalysis of data derived from a randomized clinical trial was performed. OBJECTIVE: To evaluate the association of a patient's expectation for benefit from a specific treatment with improved functional outcome. SUMMARY OF BACKGROUND DATA: Psychosocial factors, ambiguous diagnoses, and lack of a clearly superior treatment have complicated the management of patients with chronic low back pain. The authors hypothesized that patient expectation for benefit from a specific treatment is associated with improved functional outcomes when that treatment is administered. METHODS: In a randomized trial, 135 patients with chronic low back pain who received acupuncture or massage were studied. Before randomization, study participants were asked to describe their expectations regarding the helpfulness of each treatment on a scale of 0 to 10. The primary outcome was level of function at 10 weeks as measured by the modified Roland Disability scale. RESULTS: After adjustment for baseline characteristics, improved function was observed for 86% of the participants with higher expectations for the treatment they received, as compared with 68% of those with lower expectations (P = 0.01). Furthermore, patients who expected greater benefit from massage than from acupuncture were more likely to experience better outcomes with massage than with acupuncture, and vice versa (P = 0.03). CONCLUSIONS: The results of this study suggest that patient expectations may influence clinical outcome independently of the treatment itself. In contrast, general optimism about treatment, divorced from a specific treatment, is not strongly associated with outcome. These results may have important implications for clinical trial design and recruitment, and may help to explain the apparent success of some conventional and alternative therapies in trials that do not control for patient expectations. The findings also may be important for therapy choices made in the clinical setting.

Acupuncture for chronic low back pain: diagnosis and treatment patterns among acupuncturists evaluating the same patient.

BACKGROUND: There is increasing need to examine the effectiveness of acupuncture and other alternative therapies for common conditions. However, little attention has focused on the variability in acupuncturists' assessment, diagnosis, and treatment patterns. METHODS: Seven office-based acupuncturists practicing Traditional Chinese Medicine evaluated the same patient with chronic low back pain and provided data regarding principal assessment techniques, diagnoses, and therapeutic recommendations. RESULTS: A high diagnostic agreement existed among 5 of 7 acupuncturists. However, recommended treatments included varying numbers and locations of acupuncture points. Recommendations varied between 5 and 14 points requiring 7 to 26 needles, since many points were intended for bilateral application. Of 28 acupuncture points selected, only 4 (14%) were prescribed by two or more acupuncturists. Most recommended various forms of adjuvant heat. CONCLUSIONS: Seven acupuncturists agreed considerably in the diagnoses for the same patient with chronic low back pain, but treatment recommendations varied substantially. Clinicians and researchers must recognize treatment recommendation variations and the challenges they present for study design and interpretation.

Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain.

BACKGROUND: Because the value of popular forms of alternative care for chronic back pain remains uncertain, we compared the effectiveness of acupuncture, therapeutic massage, and self-care education for persistent back pain. METHODS: We randomized 262 patients aged 20 to 70 years who had persistent back pain to receive Traditional Chinese Medical acupuncture (n = 94), therapeutic massage (n = 78), or self-care educational materials (n = 90). Up to 10 massage or acupuncture visits were permitted over 10 weeks. Symptoms (0-10 scale) and dysfunction (0-23 scale) were assessed by telephone interviewers masked to treatment group. Follow-up was available for 95% of patients after 4, 10, and 52 weeks, and none withdrew for adverse effects. RESULTS: Treatment groups were compared after adjustment for prerandomization covariates using an intent-to-treat analysis. At 10 weeks, massage was superior to self-care on the symptom scale (3.41 vs 4.71, respectively; P =.01) and the disability scale (5.88 vs 8.92, respectively; P<.001). Massage was also superior to acupuncture on the disability scale (5.89 vs 8.25, respectively; P =.01). After 1 year, massage was not better than self-care but was better than acupuncture (symptom scale: 3.08 vs 4.74, respectively; P =.002; dysfunction scale: 6.29 vs 8.21, respectively; P =.05). The massage group used the least medications (P<.05) and had the lowest costs of subsequent care. CONCLUSIONS: Therapeutic massage was effective for persistent low back pain, apparently providing long-lasting benefits. Traditional Chinese Medical acupuncture was relatively ineffective. Massage might be an effective alternative to conventional medical care for persistent back pain.

How traditional Chinese medicine acupuncturists would diagnose and treat chronic low back pain: results of a survey of licensed acupuncturists in Washington State.

OBJECTIVES: This survey was undertaken to learn how Traditional Chinese Medicine acupuncturists' diagnose and treat patients with chronic low back pain in order to develop a standardized treatment for a clinical trial of that condition. DESIGN: We surveyed a randomly selected group of 56 acupuncturists in Washington State, USA about styles of acupuncture they used for treating chronic low back pain, diagnoses made, and key features of treatment for this condition. RESULTS: While substantial variability existed among practitioners, there was agreement on several broad features of treatment including: the use of local and distal acupuncture points (86% of practitioners), the use of acupuncture points on the meridians traversing the back (especially the UB meridian, 90%) the use of acupoints determined by palpation (82%), the importance of eliciting de qi (60%), and of providing up to eight treatments for achieving therapeutic results (79%). CONCLUSION: The use of practitioner surveys can enhance the systematic development of acupuncture treatment protocols and should be part of this process in future clinical trials of common conditions.

Variation in diagnosis and treatment of chronic low back pain by traditional Chinese medicine acupuncturists.

OBJECTIVES: To assess interrater reliability of Traditional Chinese Medicine (TCM) diagnosis and treatment of chronic low back pain. DESIGN: Under a Latin square design, six TCM acupuncturists evaluated the same six patients on the same day. SETTING: Northwest Institute of Acupuncture and Oriental Medicine, Seattle, Washington. INTERVENTIONS: Assessment only. OUTCOME MEASURES: TCM diagnosis, acupoint prescriptions, auxiliary treatment recommendations. RESULTS: Twenty diagnoses and 65 acupoints were used at least once. The diagnosis of Qi/Blood Stagnation with Kidney Deficiency and the acupoint UB23 were used for every patient by most acupuncturists. However, consistency across acupuncturists regarding diagnostic details and other acupoints was poor. No diagnoses, and only one acupoint, were used preferentially for a subgroup of patients. Some diagnoses and treatment recommendations were dependent more on the practitioner than on the patient. Fine-grained diagnoses and most acupoints were unrelated to either patient or practitioner. CONCLUSIONS: TCM diagnoses and treatment recommendations for specific patients with chronic low back pain vary widely across practitioners. Acupuncture clinical trials using an individualized treatment arm may be difficult to replicate or evaluate because of low concordance among acupuncturists. Comparison of individualized treatment with a thoughtfully developed standardized approach is warranted to determine which, if either, is superior.

The diagnosis and treatment of patients with chronic low-back pain by traditional Chinese medical acupuncturists.

The selection of appropriate treatments in clinical trials of acupuncture requires understanding how acupuncturists diagnose and treat specific conditions. We examined the Traditional Chinese Medical (TCM) diagnoses and treatments for patients with chronic low-back pain using two separate sets of treatment records. Information from more than 150 initial visits was available for analysis. A diagnosis of Qi and Blood Stagnation or Qi Stagnation was made for 85% of patients. A diagnosis of kidney deficiency (or one of its three subtypes) was made for 33%-51% of patients. Other specific diagnoses were made for less than 20% of the patients. An average of 12-13 needles was used in each treatment. Although more than 85 different acupoints were used in each data set, only 5 or 6 acupoints were used in more than 20 of the treatments in each data set. Only two of those acupoints (UB23, UB40) were the same for both sources of data. More than half of the patients received adjunctive treatments, including heat (36%-67%), and cupping (16%-21%). There was substantial variability in treatments among providers. Such diversity will make it challenging to select a single treatment that has wide applicability. We recommend that researchers attempt to develop a treatment that is considered credible by expert acupuncturists and has broad features characteristic of patterns of common clinical practice.

Risk factors for incident and recurrent condylomata acuminata among men. A population-based study.

BACKGROUND AND OBJECTIVES: The rapid increase in the number of physician office visits for condylomata acuminata and the association of human papillomavirus and cancer has prompted renewed interest in the epidemiology of this sexually-transmitted disease. Few epidemiologic studies have examined what risk factors are associated with condylomata acuminata in men. GOAL: To determine what factors may predispose a man to the occurrence of condylomata acuminata. STUDY DESIGN: A population-based case-control study was conducted among male members of a health maintenance organization. Patients were men 18 years or older who were seen for condyloma at one of four primary care clinics of Group Health Cooperative of Puget Sound between April 1, 1987 and September 30, 1991. Control subjects were frequency matched to the patients on clinic site, race, and age. In-person interviews were used to ascertain exposure histories from both patients and control subjects. RESULTS: Recurrent condyloma was reported by about one third of our patients. Patients with multiple partners were strongly associated with developing the disease. Several factors were either more strongly or only associated with recurrent disease. Other behavioral measures, such as recreational drug use, were also related the occurrence of condyloma. CONCLUSION: These results confirm the sexual-transmitted mechanism of condyloma in men. Exposure to multiple partners was associated with elevated risk of both recurrent and incident disease. Other cofactors may be involved in the etiology of condyloma.

Risk factors for incident and recurrent condylomata acuminata among women. A population-based study.

BACKGROUND: Condylomata acuminata is one of the most common sexually transmitted diseases (STDs) diagnosed in the United States, yet relatively little research has been conducted on the determinants of this disease in well-defined populations. GOAL: To determine the exposures that predispose a woman to the development of condylomata acuminata or genital warts. STUDY DESIGN: A population-based case-control study was conducted among enrollees of Group Health Cooperative of Puget Sound. Patients (94 women with incident and 55 women with recurrent condyloma) were diagnosed between April 1, 1987 and September 30, 1991. Control subjects were 133 women without a history of genital warts. An in-person interview was conducted to collect information on subject characteristics, exposures, and on all episodes of genital warts. RESULTS: Women with five or more partners within the 5 years before reference date were over seven times more likely to have incident condyloma (relative risk [RR], 7.5; 95% confidence interval [CI], 3.1-18.1) and over 12 times more likely to have recurrent condyloma (RR, 12.8; 95% CI, 4.2-38.9) compared with women with only one sexual partner during this time period. An increased risk of incident condyloma was also associated with a history of any STD (RR, 2.6; 95% CI, 1.1-5.8), a history of oral herpes (RR, 2.2; 95% CI, 1.1-4.4), and a history of allergies (RR, 2.0 95% CI, 1.0-3.8). Our data did not support a strong association between risk of condyloma and smoking or recent use of oral contraceptives. CONCLUSION: Our results suggest that risk of condyloma is primarily related to sexual behavior. We did not observe a strong association between risk of condyloma and many of the exposures considered to be potential cofactors for anogenital cancers associated with other types of human papillomaviruses.

Hormonal factors in vulvar cancer. A case-control study.

As part of a case-control study of vulvar cancer, we examined the role of reproductive history, menstrual history, exogenous estrogen use and body mass in the etiology of this disease. A total of 330 women with vulvar squamous cell cancer (259 in situ, 81 invasive), aged 18-79 years, who were diagnosed with this tumor during 1980-1990 were interviewed. Their responses were compared to those of 1,010 women who were selected from the general population by means of random digit dialing. Cases and controls did not differ regarding age at menopause, parity, number of prior pregnancies or number of prior births, history of miscarriage or use of noncontraceptive estrogens. Women diagnosed with vulvar cancer were slightly more likely to have experienced menarche at < 12 years (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1.2-2.7, in situ cancer; OR = 1.6, 95% CI = 0.8-3.1, invasive cancer), to have excess weight (invasive cancer only, OR = 2.9, 95% CI = 1.5-5.8 for highest tertile of Quetelet's index) and, among gravid women, to have had their first pregnancy after age 24 (in situ cancer only, OR = 1.5, 95% CI = 0.9-2.5). These data, together with similar results from previous studies and quantitative studies of hormone receptors in vulvar tissue, suggest that in situ and invasive vulvar cancer are not strongly hormone dependent tumors.

Diet and genital warts: a case-control study.

BACKGROUND AND OBJECTIVES: Clinical observations support a substantial role for impaired immunity in the development of human papillomavirus (HPV) infections. Intake of vitamins, especially vitamins A and C, and alcohol consumption have been reported to influence immune response. GOAL OF THE STUDY: To examine the relationship between nutritional risk factors, including alcohol consumption, and the risk of genital warts. STUDY DESIGN: A case-control study was conducted among enrollees at four clinics of Group Health Cooperative in western Washington state. A total of 188 cases diagnosed with condyloma from April 1, 1987 to September 30, 1991 and 245 controls completed a semi-quantitative food frequency questionnaire. RESULTS: After adjustment for socioeconomic indicators, total energy intake, smoking and sexual behavior, a weekly consumption of two to four alcoholic drinks was associated with an almost doubled risk of genital warts (OR = 1.9, 95% confidence interval [CI] = 1.0-3.6). Consuming five or more alcoholic drinks per week was even more related to the risk of genital warts (OR = 2.4, 95% CI = 1.2-5.1). The risks tended to increase with the number of alcoholic drinks (P = 0.006). Vitamin A and C intakes as measured by a food frequency questionnaire did not alter the risk of condyloma. CONCLUSION: Moderately high consumption of alcohol is associated with increased risk of condyloma. Further biological and epidemiological studies are needed to explain this association.

History of circumcision, medical conditions, and sexual activity and risk of penile cancer.

BACKGROUND: Epidemiological evidence suggests lack of neonatal circumcision as the strongest risk factor for penile cancer, but the role of sexually transmitted diseases in the etiology of penile cancer has remained unclear. PURPOSE: To further clarify risk factors for penile cancer, we examined the role of circumcision, personal characteristics and habits (such as smoking), sexually transmitted diseases, past sexual activity, and medical conditions of the penis. METHODS: A population-based, case-control study was conducted in western Washington state and in the province of British Columbia. We interviewed 110 men with penile cancer diagnosed from January 1979 to July 1990 and 355 control subjects from the general population, frequency matched to case subjects on age and date of diagnosis. Tumor tissue from 67 case subjects was tested for human papillomavirus (HPV) DNA by polymerase chain reaction. Results of blood tests from 69 case subjects and 208 control subjects were available for study. STATISTICALLY SIGNIFICANT RESULTS: Relative to men circumcised at birth, the risk for penile cancer was 3.2 times greater among men who were never circumcised and 3.0 times greater among men who were circumcised after the neonatal period. For current smokers, the risk was 2.8 times that of men who never smoked. The risk among men reporting a history of genital warts was 5.9 times that of men reporting no such history. Of 67 tumors tested for HPV DNA, 49% were positive; the majority of these positive tumors (70%) were type 16, which has been associated with anogenital carcinoma. Relative risks (RRs) associated with a reported history of penile rash or penile tear were 9.4 and 3.9, respectively. Among men not circumcised at birth, RRs associated with presence of smegma and difficulty in retracting the foreskin were 2.1 and 3.5, respectively. Twenty-eight percent of case subjects, compared with only 10% of control subjects, reported 30 or more sexual partners, and men with HPV-positive tumors were more likely to report a greater number of sexual partners. CONCLUSIONS: These results suggest that the absence of neonatal circumcision and potential resulting complications are associated with penile cancer. Additionally, medical conditions of the penis, sexual activity, infection with HPV, and smoking may increase the risk for penile cancer. IMPLICATIONS: A larger study would allow examination of interrelationships of circumcision, infection with HPV, and smoking as risk factors.

Human papillomaviruses, herpes simplex viruses, and the risk of oral cancer in men.

A population-based case-control study was conducted in western Washington state to examine the relations between infection with human papilloma viruses (HPV), herpes simplex viruses (HSV), and risk of oral squamous cell cancer in men. Interviews were completed on 131 oral cancer cases diagnosed between January 1985 and December 1989 and 136 controls frequency matched to cases on age and date of diagnosis who were obtained by random digit dialing. The risk for oral cancer among men with 30 or more sexual partners was 2.4 times that of men with four or fewer partners (95% confidence interval (CI) 1.0-5.9). Men who ever practiced oral sex had lower risk for oral cancer relative to men who never practiced oral sex (relative risk (RR) = 0.4, 95% CI 0.2-0.8). Analyses of exfoliated oral cavity cells for the presence of HPV-6 DNA with polymerase chain reaction revealed that men with an oral HPV-6 infection had 2.9 times the risk for oral cancer of noninfected men (95% CI 1.1-7.3), whereas men with an oral HPV-16 infection had 6.2 times the risk for oral cancer of noninfected men (crude RR = 6.2, 95% CI 0.7-52.2). Relative risks associated with serologically detected HSV-1 and HSV-2 infections were 0.8 (95% CI 0.3-1.7) and 1.8 (95% CI 0.7-4.6), respectively. The authors conclude that HPV-6 is associated with oral cancer. Although men infected with HPV-16 and HSV-2 were at elevated risk, these associations may have been due to chance. The role of specific sexual practices in the transmission of viruses to the oral cavity remains unclear.

The association of human papillomavirus antibodies with cervical cancer risk.

The association between viral human papillomavirus (HPV) DNA and cervical carcinoma has been well documented. However, less is known about the immune response to HPV infections and its relationship to cervical cancer risk. A higher prevalence of antibodies to HPV16 E7 among women with cervical cancer compared with controls has been reported, but reactivity to other antigens has not been systematically examined. Prevalence of serum IgG antibody reactivities to HPV6-encoded L1 and L2 and to HPV16- and HPV18-encoded E2, E4, E6, E7, L1, and L2 bacterial fusion proteins in a Western immunoblot assay were measured among cases with invasive cervical cancer (n = 69) and control women (n = 81). The intensities of the Western blot bands were graded as +1, +2, or +3 (0 = negative). Antibodies to HPV6 L1 and L2, HPV16 E7 and L2, and HPV18 L2 fusion proteins were observed among 39-62% of cases and 33-71% of controls. After systematic sampling for antibody reactivity to this range of fusion proteins, the sample was expanded to include 150 cases and 145 controls tested exclusively for reaction to HPV6 L1 and L2, HPV16 E7, and HPV16 and HPV18 L2. Relative risk was estimated for > or = +1, +1, and > or = +2 levels of reactivity after adjustment for confounding factors. Except for HPV16 E7, reactivity at the > or = +1 level did not distinguish cases from controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship between human papillomavirus infection and tumours of anogenital sites other than the cervix.

Although tissues in the case series of anal, penile, vaginal and vulvar neoplasms that have looked for evidence of HPV infection by probing for HPV DNA have been selected for convenience, they support the view that HPV, especially type 16, is associated with approximately 50% of these tumours. A higher percentage of the anal, vaginal and vulvar tumours are associated with HPV 16 than are penile tumours. This discrepancy may be due to the low number of penile tumours studied or to a true difference in the proportion of penile cancer cases related to HPV. HPV 6/11 and 18 are found less frequently at all anatomic sites. About 10% of tumours that are probed for these viruses are positive, although there are some notable exceptions such as a study that found 39% of penile tumours positive for type 18 and a study that found approximately two thirds of vulvar tumours positive for HPV 18 using Southern blot hybridization. For all of these tumours, there is likely to be a subset of the cases who develop their cancer through mechanisms that do not involve HPV. The case-control studies found a strong association with genital warts, number of sexual partners and, with the exception of vaginal cancer, smoking and/or heavy smoking at the time of diagnosis of the disease. A history of genital warts, smoking at diagnosis, and seropositivity to HSV2 are exposures that have also been found to be associated with cervical cancer. A population-based case-control study in western Washington and Vancouver, British Columbia that studied all anogenital cancers found that a history of genital warts was stronger among patients with vulvar, anal, vaginal and penile cancer than among those with cervical cancer. This was also true of smoking at diagnosis, with the exception of vaginal cancer, where there was little excess risk. This study and other supporting data indicate that these anogenital tumours share many of the same risk factors as cervical cancer.

Cigarette smoking and the risk of anogenital cancer.

The association between cigarette smoking and cervical cancer has been demonstrated in numerous prior studies. As part of population-based case-control studies of cancers of the vulva, vagina, cervix, anus, and penis in relation to infection with human papillomavirus, conducted in western Washington State and the province of British Columbia from the mid 1980s until the present time, the authors have collected detailed information on smoking history. The proportion of subjects who were current smokers of cigarettes ranged from slightly over 40% among incident cases of vaginal and cervical cancer to 60% among cases of vulvar and anal cancer. In contrast, only about 25% of controls were current smokers. The adjusted odds ratios (OR) associated with current smoking were substantially elevated (OR = 1.9-14.6) for all cancer sites except cancer of the vagina (OR = 1.3). The risks tended to increase in proportion to the number of cigarettes smoked. For most cancer sites, the odds ratios associated with former smoking were substantially less than those associated with current smoking and diminished with increasing time since cessation of smoking. The authors' data and those of other investigators suggest that cigarette smoking plays a role in the etiology of anogenital cancers and that smoking has a late-stage or promotional effect.

Genital-type human papillomavirus infection is not associated with surface epithelial ovarian carcinoma.

Tumor tissues from 29 women with borderline or malignant epithelial ovarian tumors were examined for the presence of human papillomavirus (HPV) DNA by the polymerase chain reaction (PCR). The PCR analysis used a set of consensus primers that are complementary to highly conserved sequences in the genital HPVs (M. M. Manos, Y. Ting, D. K. Wright, A. J. Lewis, T. R. Broker, and S. M. Wolinsky, Cancer Cells 7, 209-214, 1989). Amplification products were detected by Southern hybridization with consensus oligonucleotide probes. A total of 70 paraffin-embedded tissue sections from ovarian carcinomas were tested and we did not detect genital-type HPV DNA sequences in any of these specimens. However, all of the tissue specimens were considered adequate for PCR analysis because a human cellular gene (beta-globin) was successfully amplified in each tissue specimen. In addition, HPV 16 DNA was found in a concurrent invasive squamous-cell carcinoma of the cervix from one ovarian cancer patient, indicating that the PCR was able to detect HPV in the lower genital tract of this individual. We conclude that there is no association between infection with the most common genital HPVs and borderline and malignant epithelial ovarian tumors.