Thesis (PhD)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Introduction Cisplatin has been widely used to treat solid tumours and much success has come from the use of this drug in the treatment of head and neck, ovarian, testicular, cervical and small-cell lung cancers. However, the success of cisplatin treatment is limited due to its dose-limiting toxicity and its resulting side-effects, such as nephro- and ototoxicity. The devastating side-effects induced by cisplatin treatment provided the platform for this study whereby the aim was to lower the concentration of cisplatin while maintaining its cancer-specific cytotoxic action. Equally concerning is, cisplatin resistance which is becoming increasingly common, and this radically limits the clinical efficacy and utility of the drug. Adjuvant therapy has thus become necessary in an attempt to possibly curb or lessen the extent of cisplatin resistance. Due to the large body of evidence implicating the importance of autophagy in cancer, the prospect of targeting this mechanism has generally been accepted. Various chemotherapy agents induce autophagy in cancer cells; however the effect of cisplatin on autophagic induction has not been very well explored. We thus hypothesise that the manipulation of the autophagic pathway will sensitise cancer cells to a low concentration of cisplatin treatment. Furthermore, due to the functional interaction between Bcl-2 and Beclin-1 and its role in the regulation of autophagy, ratio analysis of Beclin-1 to Bcl-2 as means of detecting the role of autophagy within the cell under homeostatic and treatment/stress conditions has been conducted. Additionally, Bcl-2 has a prominent role in the malignant cell and it’s over-expression has been found to confer resistance in a variety of cancerous cell lines. We therefore hypothesise that the silencing of Bcl-2 prior to cisplatin treatment will sensitise cervical cancer cells to apoptosis and increase the Beclin-1/Bcl-2 ratio in favour of apoptosis. Materials and Methods Three human cervical cell lines were used: a non-cancerous ectocervical epithelial cell line (Ect1/E6E7) and two cancerous cervical cell lines (HeLa and CaSki). In order to determine a concentration of cisplatin that was non-toxic to the non-cancerous Ect1/E6E7 cell line, a dose-response was performed. With the use of an autophagy inhibitor (bafilomycin A1) and an autophagy inducer (rapamycin), autophagic flux capacities were assessed in each cell line through the Western blotting technique. In order to assess whether the chosen concentration of cisplatin induced autophagy, flow cytometry with the use of a Lysotracker™ dye was utilised, as well as analysis of autophagy protein levels (LC-3 II, Beclin-1 and p62). Autophagy modulation was achieved through two methods: pharmacological modulation with use of two recognised agents, namely bafilomycin A1 and rapamycin, and biological manipulation with the use of ATG5 and mTOR mRNA silencing. The effects of different treatment regimes on cell death was assessed with the use of PARP and caspase-3 cleavage through Western blotting, caspase-3/-7 activity (Caspase-Glo®), PI inclusion, LDH release and MTT reductive capacity. Additionally the effects of these treatment regimes on cell-cycle progression were also analysed. Beclin-1 and Bcl-2 expression was determined through Western blotting and immunocytochemistry before and after treatment with cisplatin in HeLa and CaSki cells. To assess the reliance of the cervical cancer cells on Bcl-2 after cisplatin treatment, Bcl-2 knock-down was achieved through RNA interference, where after the Beclin-1/Bcl-2 ratio was assessed as well as apoptosis with the use of cleaved PARP analysis (Western blotting) and Caspase-Glo©. For the ex vivo analysis, biopsies were collected from patients undergoing routine colposcopy screenings and hysterectomies at Tygerberg Hospital, Tygerberg, Western Cape. A total of 10 normal, 29 low-grade squamous intraepithelial lesions (LSIL), 33 high-grade squamous intraepithelial lesions (HSIL) and 13 carcinoma biopsies were collected for analysis, where after the expression profiles of two autophagy markers (mTOR and LC-3 II), as well as one anti-apoptotic marker (Bcl-2) were assessed. Protein levels were analysed through Western blot and confirmed through immunohistochemistry. Results Dose-response curves revealed that 15 μM of cisplatin did not induce cell death in the normal cervical epithelial cell line (Ect1/E6E7) and was therefore utilised through-out the remainder of the study. It was additionally determined that the CaSki cells were more resistant to cisplatin treatment when compared to the HeLa and Ect1/E6E7 cells. Autophagic flux analysis revealed that, although all three cell lines were cervix derived, their autophagic flux capacities differed. It was observed that the chosen concentration of cisplatin was able to induce autophagy in all three cell lines, with the HeLa cells demonstrating a particularly pronounced response. Autophagy modulation in conjunction with cisplatin treatment revealed the following: Autophagy inhibition with bafilomycin A1 lead to significant increases in caspase-3 and PARP cleavage and LDH release in both cervical cancer cell lines. The inhibition of autophagy through silencing of ATG5 induced caspase-3 cleavage and agrees with results obtained from pharmacological inhibition of autophagy with bafilomycin A1. In addition to autophagic induction, a low concentration of cisplatin induced the up-regulation of Bcl-2, which when silenced significantly improved cisplatin-induced apoptosis in both cervical cancer cell lines. Analysis of the expression profiles of mTOR and LC-3 in normal, pre-malignant (LSIL and HSIL) and cancerous cervical tissue revealed that autophagy is significantly up-regulated in HSILs and carcinoma of the cervix. Additionally, Bcl-2 expression is significantly increased in cervical carcinoma tissue, which agrees with results from other studies. Conclusion Autophagic flux capacities between the three cell lines investigated, derived from the same organ, differ significantly. This should be taken into consideration when autophagic modulation is being used as an adjuvant treatment. With regard to chemotherapy treatment in cervical cells, a low-concentration of cisplatin significantly induces autophagy in malignant and non-malignant cervix-derived cell lines where it serves a pro-survival mechanism. Inhibition of autophagy with bafilomycin A1 and ATG5 siRNA confirmed this survival effect in both cancerous cell lines where apoptosis was significantly increased. Interestingly, rapamycin pre-treatment together with cisplatin did not induce significant levels of apoptosis in HeLa cells where autophagy induction may have provided additional protection from the cytotoxic effects of cisplatin. Therefore the inhibition of autophagy through pharmacological and biological inhibition improves the cytotoxicity of a low concentration of cisplatin and provides a promising new avenue for the future treatment of cervical cancer. Bcl-2 up-regulation in response to cisplatin treatment also serves as a protective mechanism by which cervical cancer cells survive. The extent of apoptotic cell death observed after biological inhibition of Bcl-2 reiterates the fact that this response may be exploited in order to favour the use of lower concentrations of cisplatin. Analysis of clinical specimens emphasised the value of the in vitro work: Cervical cancer biopsies had increased expression of both LC-3 II and Bcl-2, indicating autophagy induction and apoptosis inhibition, respectively. Thus two novel methods of improving cisplatin cytotoxicity have been demonstrated in the following study. Treatment regimens may administer more frequently and prolonged due to the minimal side-effects that accompanies low-dose cisplatin treatment. / AFRIKAANSE OPSOMMING: Inleiding Sisplatien word algemeen gebruik vir die behandeling van soliede gewasse. Baie sukses is reeds deur die gebruik van díe middel behaal in die behandeling van kop en nek, ovariale, terstikulêre, servikale en klein-sel kankers. Die sukses van Sisplatien-behandeling word wel ingeperk deur die dosis-beperkende toksisiteit en die gevolglike newe-effekte soos nefrotoksisiteit. Hierdie verwoestende newe-effekte wat deur sisplatien behandelings geïnduseer word, het as die platform vir hierdie studie gedien. Die doel was om die sisplatien konsentrasies te verlaag, maar terselfdertyd die kankerspesifieke sitotoksisiteit te behou. Nog ʼn punt van kommer is dat sisplatien-weerstandigheid aan die toeneem is, wat die kliniese effektiwiteit en gebruik van hierdie middel geweldig beperk. Byvoegmiddels het dus noodsaaklik geraak in die poging om die sisplatien-weerstandigheid te verhoed. As gevolg van verskeie bewyse wat die belangrikheid van outofagie in kanker impliseer, is die vooruitsig om hierdie meganisme te teiken, algemeen aanvaar. Verskeie chemoterapeutiese middels induseer outofagie in kanker selle, hoewel die effek van Sisplatien op outofagiese induksie nog nie goed ondersoek is nie. Ons hipotese is dus dat die manipulasie van die outofagiese pad die kankerselle sensitiseer tot ʼn lae konsentrasie van sisplatien. Verder, as gevolg van die funksionele interaksie tussen Bcl-2 en Beclin-1, en hul rol in die regulering van outofagie, is verhouding-analises van Beclin-1 tot Bcl-2 uitgevoer met die doel om die rol van outofagie in die sel onder homeostatiese en behandeling/stres kondisies te bepaal. Verder is Bcl-2 bekend daarvoor om ʼn prominente rol te speel in kwaadaardige selle, en die ooruitdrukking daarvan is gevind om weerstandigheid aan te help in ʼn verskeidenheid van kankeragtige sellyne. Ons hipotetiseer dus dat geenonderdrukking van Bcl-2 voor die behandeling met sisplatien die servikale kanker selle sal sensitiseer tot apoptose en ʼn verhoging in die verhouding van Beclin-1/Bcl-2 veroorsaak, wat in die guns van apoptose is. Materiale en Metodes Drie menslike servikale sellyne was gebruik: ʼn nie-kankeragtige servikale epiteel sellyn (Ect/E6E7) en twee kankeragtige servikale sellyne (HeLa en CaSki). Om ʼn konsentrasie van sisplatien te bepaal wat nie-toksies tot die nie-kankeragtige Ect1/E6E7 sellyn is, was ʼn dosisrespons uitgevoer. Met die gebruik van ʼn outofagiese inhibeerder (bafilomycin A1) en ʼn outofagiese induseerder (rapamycin), is die outofagiese-fluks kapasiteite van elke sellyn deur die Western Blotting tegniek geassesseer. Om te bepaal of die gekose konsentrasie van sisplatien outofagie induseer, is vloeisitometrie met ʼn Lysotracker™ kleurstof gebruik, sowel as analises op outofagie proteïenvlakke (LC-3 II, Beclin-1 en p62). Outofagie modulering is behaal deur twee metodes: farmakologiese modulering met twee erkende middels, naamlik bafilomycin A1 en rapamycin, en biologiese manipulasie met die gebruik van ATG5 en mTOR geenonderdrukking. Die effekte van die verskillende behandeling skedules op seldood was geassesseer deur gebruik te maak van PARP en kaspase-3 splitsing deur Western Blotting, kaspase-3/-7 aktiwiteit deur Caspase-Glo ®, PI-insluiting, LDH vrystelling en MTT reduserende kapasiteit. Verder is die effekte van hierdie behandeling skedules op selsiklus progressie ook geanaliseer. Beclin-1 en Bcl-2 uitdrukking was ook bepaal deur Western Blotting en immunohistochemie voor en na behandeling met sisplatien in HeLa en CaSki selle. Om die afhanklikheid van die servikale kankerselle op Bcl-2 na sisplatien behandelings te toets, is Bcl-2 onderdruk deur RNA-inmenging, waarna Beclin-1/Bcl-2 verhouding geassesseer is, sowel as opoptose deur die gebruik van gesplitste PARP analises (Western Blotting) en Caspase-Glo©. Vir die ex vivo analises is biopsies vanaf pasiënte wat roetine kolposkopie en histerektomies ondergaan, verkry (Tygerberg Hospitaal, Tygerberg, Westelike Provinsie). ʼn Totaal van 10 normale, 29 lae-graad plaveisel intraepiteel letsels (LSIL), 33 hoe-graad plaveisel intraepiteel letsels (HSIL) en 13 karsinoom biopsies is verkry vir analises. Die uitdrukkingsprofiel van twee outofagiese merkers (mTOR en LC-3 II), asook een merker vir apoptose (Bcl-2), was geassesseer. Proteïen vlakke was ook deur Western Blotting geanaliseer en deur immunohistochemie bevestig. Resultate Dosisrespons kurwes het getoon dat 15 μM sisplatien nie seldood in die normale sellyn (Ect1/E6E7) geïnduseer het nie, en was daarom gebruik deur die res van hierdie studie. Verder is daar ook gevind dat CaSki selle meer weerstandig tot sisplatien behandelings is wanneer vergelyk word met die HeLa en Ect1/E6E7 selle. Outofagiese-fluks analises het getoon dat, alhoewel al drie sellyne vanaf die serviks afkomstig is, daar verskille is in hul outofagiese-fluks kapasiteit. Daar is ook waargeneem dat die gekose konsentrasie van sisplatien in staat was om outofagie te induseer in al drie sellyne, met HeLa selle wat die mees merkbare respons getoon het. Modulering van outofagie in samewerking met sisplatien behandelings het die volgende onthul: inhibisie van outofagie deur bafilomycin A1 het gelei tot ʼn beduidende verhoging in kaspase-3, PARP splitsing en LDH vrylating in beide servikale kankersellyne. Geenonderdrukking van ATG5 induseer kaspase-3 splitsing en stem ooreen met resultate wat verkry is deur farmakologiese inhibisie van outofagie met bafilomycin A1. Bykomend tot outofagiese indusering, het ʼn lae konsentrasie sisplatien die opregulering van Bcl-2 geïnduseer. Wanneer Bcl-2 geenonderdrukking in hierdie scenario toegepas was, het dit ʼn beduidende verbetering in sisplatien-geïnduseerde apoptose in beide servikale kankersellyne getoon. Analises van die uitdrukkingsprofiel van mTOR en LC-3 in normale, pre-maligne (LSIL en HSIL) en kankeragtige servikale weefsel, het getoon dat outofagie beduidend opgereguleer is in HSILs en servikale karsinome. Verder is Bcl-2 uitdrukking ook gevind om beduidend verhoog te wees in servikale karsinoomweefsel, wat ooreenstem met resultate verkry in ander studies. Gevolgtrekking Outofagiese-fluks kapasiteite tussen die drie sellyne, afkomstig van dieselfde orgaan, toon beduidende verskille. Hierdie bevinding moet in ag geneem word wanneer outofagiese-modulering as ʼn bevorderingsbehandeling gebruik word. Met betrekking tot chemoterapie behandeling in servikale selle; ʼn lae konsentrasie van sisplatien veroorsaak ʼn beduidende indusering van outofagie in kwaadaardige en nie-kwaadaardige serviks-afkomstige sellyne, en dien as ʼn oorlewingsmeganisme. Inhibisie van outofagie met bafilomycin A1 en ATG5 siRNA het hierdie beskermings effek bevestig, aangesien apoptose beduidend verhoog was in beide kankersellyne. Interessant genoeg het rapamycin pre-behandeling tesame met sisplatien nie beduidende vlakke van apoptose in HeLa selle geïnduseer nie. Outofagie induksie mag dalk addisionele beskerming teen die sitotoksiese effekte van sisplatien gebied het. Daarom het die inhibisie van outofagie deur farmakologiese en biologiese inhibering die sitotoksisiteit van ʼn lae konsentrasie sisplatien bevorder, wat ʼn belowende bevinding is vir die toekomstige behandeling van servikale kanker. Bcl-2 opregulering as gevolg van sisplatien behandelings dien ook as beskermings meganisme waarby servikale kankerselle oorleef. Die mate van apoptotiese seldood wat waargeneem word na biologiese inhibering van Bcl-2, wys weer op die feit dat hierdie respons uitgebuit kan word vir die gebruik van laer konsentrasies van sisplatien. Analises van die kliniese monsters het ook die waarde van die in vitro werk versterk: Servikale kanker biopsies het verhoogde uitdrukking van beide LC-3 II en Bcl-2 getoon, wat aandui dat outofagie geïnduseer en apoptose geïnhibeer word. Daar is dus twee nuwe metodes vir die verbetering van sisplatien-toksisiteit in hierdie studie gedemonstreer. Behandeling regimes kan meer gereeld en vir langer tydperke toegepas word, aangesien die newe-effekte van lae-dosis sisplatien behandelings minimaal is. / MRC for funding

This study aimed to understand how the identity of Manitobans with early malignancy is affected through diagnosis, decision making and treatment. Using grounded-theory methodology, semi-structured interviews were conducted with 18 adult patients with early breast, colon, lung, prostate and gynecological cancers, before and after adjuvant treatment decision making. 15 adult friends and family members were also interviewed. Significant findings include: 1) After diagnosis, the “cancer identity” emerged as a new aspect of the patient’s identity; 2) Establishing a post-diagnosis routine was a significant source of distress for patients; 3) Ability to re-establish routine post-diagnosis may be enhanced by providing earlier notification of medical appointment times and information regarding how different treatment options will affect the patient’s identity. This study provides new insight into the experience of patients with malignancy in Manitoba. Additionally, it presents recommendations, based on the insights and concerns of its participants, for improving the cancer journey of Manitobans. / May 2017

Bakgrund Extern strålbehandling är en viktig del av processen för behandling av cervikal cancer. Målet med denna typ av behandling är att bestråla tumörområdet med så hög dos som möjligt och omkringliggande frisk vävnad med så lite dos som möjligt. Ett problem som upptäckts är att rörelser i tumörområdet under behandling kan påverka precisionen av strålfältet. Syfte Syftet med litteraturstudien var att beskriva omfattning av rörelse och volymförändring i tumörområdet under strålbehandling av cervikal cancer. Metod                  Nio artiklar med kvantitativ design kvalitetsgranskades och resultaten sammanställdes med inspiration av Fribergs modell. Resultat Omfattning av rörelser och volymförändringar upptäcktes variera och är något som skiljer sig mellan individer. Valet av bildtagnings- och mätmetod har stor betydelse gällande patientsäkerhet och stråldos.   Slutsats Hur mycket tumörområdet rör sig/förändras i volym var något som varierade mellan patienterna i studierna och det är därför viktigt att anpassa behandlingen efter dessa variationer. Olika metoder för bildtagning och mätning kan användas både för att upptäcka rörelser och volymförändringar i tumörområdet under extern strålbehandling. De olika metodernas fördelar bör noggrant vägas mot nackdelar innan användning för att hitta en optimal metod som främjar patientsäkerhet. / Background External radiation therapy is an important part when treating cervical cancer. The goal of this type of therapy is to irradiate the tumor area with the highest possible dose and minimize the dose given to the surrounding healthy tissue. One problem showed is that movement in the tumor area during treatment can cause problems regarding keeping the precision as high as possible. Aim The aim of this literature study was to describe the extent of movement and volume change in the tumor area during external radiotherapy treatment of cervical cancer. Method Nine articles with quantitative design were quality-reviewed and the results were compiled with inspiration from Friberg's model. Results The extent of movements and volume changes was discovered varying and is something that differs between individuals. The choice of imaging and measurement method is of great importance in terms of patient safety and radiation dose. Conclusions The extent of movement and change in volume varied between patients in the studies and it is therefore important to adjust the treatment according to these variations. Different methods of imaging and measurement can be used both to detect movements and volume changes in the tumor area during external radiation therapy. The benefits of the different methods should be carefully weighed against disadvantages before use to find an optimal method that promotes patient safety.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal.

Le cancer du col représente un problème de santé publique au Marco. L’objectif principal de cette thèse est d’améliorer les connaissances sur le cancer du col de l’utérus au Maroc en terme d’épidémiologie descriptive et analytique notamment par l’étude des principaux facteurs associés à ce cancer, son retard de diagnostic et sa prise en charge.Méthodologie Pour répondre à notre objectif, trois études ont été menées. La première étude, rétrospective sur dossier d’hospitalisation, sur les stades de diagnostic et les résultats des traitements du cancer du col. La deuxième étude, transversale, sur les facteurs liés au retard de diagnostic du cancer du col et la troisième étude, cas-témoins multicentrique avec appariement individuel sur l’âge, sur les facteurs de risque du cancer du col de l’utérus. Résultats La première étude a montré la vulnérabilité socioéconomique de la population des femmes atteintes de cancer du col et a mis le point sur les problèmes du retard de diagnostic et de l’accessibilité aux établissements de soins auxquels elles sont confrontées. L’étude a mis l’accent sur la durée du suivi insuffisante et le nombre élevé des perdues de vue. La deuxième étude, a montré que les femmes âgées de moins de 50 ans, analphabètes, non mariées, les femmes au foyer, les femmes résidant en milieu rural, les femmes résidant à plus de 100Km du lieu du diagnostic du cancer, les femmes sans antécédents de cancer du col et les femmes n’ayant pas eu comme premier symptôme des saignements gynécologiques étaient plus à risque du retard de diagnostic du cancer du col. L’étude cas-témoins a confirmé que l’infection à HPV est le facteur de risque majeur du cancer du col. Les autres facteurs de risque du cancer invasif du col utérin étaient : la parité élevée, le faible niveau d'éducation, l’existence de multiples partenaires sexuelles chez le mari, les rapports sexuels pendant les menstruations et les antécédents d’IST. La limite majeure de notre étude cas-témoins est liée au manque de puissance statistique pour l’étude de l’association avec d’autres facteurs tels que les facteurs nutritionnels. Conclusion Les études réalisées dans le cadre de notre thèse, en dépit de leurs limites, constituent une source d’information pour la recherche scientifique sur le cancer du col au Maroc et dans les pays similaires. Elles contribuent à l’amélioration des connaissances sur le cancer du col au Maroc et par là des attitudes et pratiques des différents corps sanitaires vis-à-vis de ce cancer. Elles ont permis de définir les populations à risque de cancer du col et à risque de retard de diagnostic et, ainsi de mieux les cibler dans les programmes de dépistage d’information et d’éducation. Les résultats de nos travaux de recherche pourraient représenter une « situation de référence » utile pour tout programme d’évaluation concernant le cancer du col au Maroc. Ceci devrait permettre dans le futur de mieux évaluer à long terme l’efficacité des programmes de dépistage, de vaccination, des traitements et de l’éducation pour la santé. / The main objective of this work was to improve knowledge about cervical cancer in Morocco in terms of descriptive and analytical epidemiology including the study of the main factors associated with cancer, the delay in diagnosis and its management. Methods : To meet our objectives, we conducted three studies. The first (Study of diagnosis stages and treatment outcomes for cervical cancer), is a retrospective study using data from hospital records of patients with cervical cancer in the major cancer centers in Morocco. The second study (Study of factors related to delay in diagnosis of cervical cancer), transversal, with recruitment of cervical cancer patients. The third study (Study of risk factors for cervical cancer) was a multicenter case-control study with individual matching on age. Results : The first study showed the socio-economic vulnerability of the population of women with cervical cancer and the problems of delayed diagnosis and access to health facilities. In addition, this study focused on the inadequate length of the follow-up and the high number of lost to following-up. The second study showed that women aged less than 50 years, illiterate, unmarried, women at home, women living in rural areas, women living more than 100km from the place of cancer diagnosis, women without history of cervical cancer and women who have not had, as the first symptom, a gynecological bleeding were more at risk of delayed diagnosis of cervical cancer. The case-control study confirmed that HPV infection is the major risk factor for cervical cancer. The other risk factors for invasive cervical cancer identified in our study were: the high parity, the low educational level, husband's multiple sexual partners, sex during menstruation and the history of venereal diseases. Conclusion : The studies conducted in the context of our thesis, inspite of their limitations, are considered as a rich source of information for scientific research on cervical cancer in Morocco and in similar countries. They have improved the knowledge on cervical cancer in Morocco and thus should improve the knowledge, attitudes and practice of different health practitioner’s for cervical cancer. They helped to define population at risk of cervical cancer and of delayed diagnosis. Therefore, it allows them to be better targeted by the screening, information and education programs. The results of our research also represent a "reference situation" for any evaluation program for cervical cancer in Morocco. This should help, in the future, to better assess the long-term effectiveness of screening programs, vaccination, treatment and health education.

Cervical cancer is a major cause of death in women and is strongly associated with infection by human papillomavirus (HPV). Integration of HPV is thought to form a key step in the formation of cancer, and is thought to involve the upregulation of HPV E6 and E7 due to the loss of E2 transcriptional control. Leptomycin B (LMB), a nuclear export inhibitor, has previously been shown to induce apoptosis in HPV-containing cancer cell lines and HPV 16 E7 or E6/E7 transduced primary keratinocytes, but not in normal cells. This thesis shows that LMB can induce apoptosis and a reduction in the colony survival of derivatives of the W12 cell line that contain HPV 16 in either episomal or integrated form. The HPV genome status, including variations in viral integration type, appears to influence the cumulative and temporal pattern of LMB-induced apoptosis. The effects of LMB were also apparent in cells grown in organotypic raft culture, with differences in behaviour again apparent between cells containing episomal and integrated HPV. As previously noted, treatment with LMB was associated with increased expression of the cell regulators p53 and p21; however, the induction of apoptosis was not dependent upon transcriptionally active p53. It is therefore likely that induction and mediation of LMB-induced apoptosis occurs via alternative, currently unidentified, pathways. These findings suggest that LMB can induce apoptosis in keratinocytes containing HPV 16 in either episomal or integrated form, with genome status and potentially lesion grade likely to influence the response of HPV-associated anogenital lesions to LMB treatment.

Bakgrund: HPV är den vanligaste sexuellt överförda infektionen i världen. Över en halv miljon kvinnor världen över drabbas av cervixcancer varje år där HPV är den primära orsaken. Föräldrars attityder kring faktorer rörande HPV-vaccin till deras barn spelade en avgörande roll för hur många som erhöll vaccinet. Föräldrar valde att inte vaccinera sina barn på grund av attityder och stigman som kom från omgivningen och samhället. Syfte: Att undersöka faktorer som påverkar attityder hos föräldrar kring HPV-vaccin till deras barn. Metod: Arbetet var en litteraturöversikt för att kartlägga det valda området, med analys av valda artiklarna. Artiklarna var vetenskapliga, skrivna på engelska och med kvalitativ grund. Resultat: Rätt information från sjuksköterskor till föräldrar ledde till positiva attityder, däremot var avsaknad av information angående vaccinets säkerhet och effekt en bidragande orsak till tvekan hos många föräldrar. Ekonomi, medias attityder, synen på sex samt rädsla för biverkningar påverkade föräldrars val att vaccinera sina barn. Åsikter kring lämplig ålder hos barnet vid erhållandet av vaccinet gick isär.Slutsats: Föräldrars attityder påverkade i stor grad andelen barn som vaccinerades. Ökad kunskap till föräldrar angående HPV och vaccinets verkan skulle leda till ett högre vaccinationstal och således förbättrad hälsa globalt. / Background: HPV is the most common sexually transmitted infection in the world. Over half a million women in the world suffer from cervical cancer each year were HPV-virus is the primary reason. Parents attitudes towards HPV vaccine for their children played a crucial part in how many actually got provided with the HPV-vaccine. Parents chose not to vaccinate their children because of attitudes and stigma that was founded in environments and communities. Aim: To examine factors that affect parents attitudes about HPV vaccine to their children. Methods: The chosen method was a literature review as topic, to explore the chosen subject and analyzing suitable articles. The articles have been scientific, in English and with qualitative reasons. Results: The right information from nurses to parents led to positive attitudes, however, the lack of information regarding the safety and efficacy of the vaccine was a contributing cause of doubt among many parents. Economics, media attitudes, views on sex and fear of side effects affected the parents' choice to vaccinate their children. Opinions about the appropriate age of the child when obtaining the vaccine went apart. Conclusions: Parents' attitudes largely affected the percentage of children who were vaccinated. Increased parents’ knowledge regarding HPV and the effect of the vaccine would lead to a higher vaccination rate and thus improved health globally

O câncer cervical é o segundo câncer mais comum entre as mulheres em todo o mundo. A infecção por Papilomavirus (HPV) do tipo oncogênico é causa necessária. Estudos internacionais sugerem importante papel de carotenóides e tocoferóis séricos e dietéticos na redução do risco para lesões precursoras, mas os resultados dos estudos prévios são inconsistentes. Indivíduos e métodos: O presente estudo de casos e controles de base hospitalar conduzido na cidade de São Paulo analisou a associação entre concentrações séricas de carotenóides (licopeno, β-caroteno), tocoferóis (α- e γ-), consumo alimentar e casos incidentes, com confirmação histopatológica, de neoplasia intraepitelial cervical (NIC) graus 1,2,3 e câncer cervical. O estudo incluiu 453 mulheres do grupo controle (sem lesões de colo uterino) e 4 grupos de casos (NIC1, n=140; NIC2, n=126; NIC3, n=231; câncer cervical, n=108) recrutadas em dois hospitais públicos de referência entre 2003 e 2005. Resultados. A concentração sérica de licopeno foi inversamente associada à NIC1, NIC3 e câncer cervical com os seguintes Odds Ratio (OR) (intervalo de confiança de 95%), respectivamente: 0,53 (0,27-1,00; p de tendência=0,05); 0,48 (0,22-1,04; p de tendência=0,05) e 0,18 (0,06-0,52; p de tendência=0,002) quando comparado o maior com o menor tercil após ajuste por variáveis de confusão e grupos de HPV. O maior tercil de β-caroteno sérico foi inversamente associado ao câncer quando comparado ao menor: OR ajustado = 0,36 (0,13-1,03: p de tendência=0,04). Maiores concentrações de α- e γ-tocoferóis foram inversamente associadas a NIC3 com redução do risco em 50%, após ajuste por covariáveis e HPV. Maior tercil de consumo do grupo de folhas verde-escuras, legumes e frutas de cor alaranjada ou amarela escura foi inversamente associado ao risco para NIC3: OR ajustado comparado ao menor foi 0,52 (0,27-1,00; p de tendência=0,05). Conclusão: Os resultados do presente estudo sugerem que maiores concentrações séricas de antioxidantes e o consumo de alimentos ricos em carotenóides podem reduzir o risco para NIC3 e câncer cervical em mulheres brasileiras. / Cervical cancer is the second most common cancer in women worldwide. Human papillomavirus (HPV) infection has been recognized to be a necessary cause for cervical cancer. Serum concentrations and dietary carotenoids and tocopherols have been associated with the risk for cervical dysplasia, but results from previous studies were not consistent. Subjects and methods: In this hospital-based case-control study conducted in São Paulo city, Brazil, we evaluated the association of serum carotenoids (β-carotene, lycopene), tocopherols (α- and γ-), and dietary intakes with the risk of incident histologically confirmed cervical intraepithelial neoplasia (CIN) grades 1, 2, 3, and cervical cancer. The sample included 453 controls and four groups of cases (CIN1, n= 140; CIN2, n= 126; CIN3, n= 231; invasive cancer, n=108) recruited from two major public hospital-based clinics between 2003 and 2005. Results. Concentrations of serum lycopene were negatively associated with CIN1, CIN3 and cancer, with odds ratio (OR) (95% confidence interval) for the highest compared with the lowest tertile of 0.53 (0.27-1.00, p trend=0.05) for CIN1, 0.48 (0.22-1.04, p trend=0.05) for CIN2 and 0.18 (0.06-0.52, p trend= 0.002) for cervical cancer adjusted for confounding variables and HPV status. The adjusted OR for cancer of the highest versus the lowest tertile of serum β-carotene was 0.36 (0.13-1.03, p trend= 0.04). Increasing concentrations of serum α- and γ-tocopherols were associated with 50% decreasing risk of CIN3, for the women in the highest compared with the lowest quartile after adjusting for confounding variables and HPV. Increased dietary intakes of dark green and deep yellow vegetables and fruits were inversely associated with CIN3 among women in the highest compared to the lowest tertile (adjusted OR= 0.52, 95%CI = 0.27-1.00; p trend=0.05). Conclusion: These results support the evidence that high serum levels of antioxidants as well as dietary intakes may reduce the risk for CIN3 and invasive cancer in Brazilian women.

A infecção por tipos de HPV de alto risco oncogênico é o principal fator de risco para o desenvolvimento do carcinoma do colo uterino, uma das neoplasias mais frequentes em mulheres de todo o mundo. Este grupo de vírus também está associados a uma proporção importante de outros cânceres anogenitais e de tumores de cabeça e pescoço. Os HPVs de alto risco expressam duas oncoproteínas, E6 e E7, que agem sobre fatores celulares específicos alterando diferentes vias de vinalização. A oncoproteína E6 é capaz de unir-se à proteína supressora de tumor p53, alterar a sua capacidade funcional e promover sua degradação pela via de proteólise dependente de ubiquitina. Mais ainda, a interação da proteína E6 com várias proteínas celulares por exemplo, E6AP, TNFR1, Bak e caspase 8 confere resistência a apoptose; hADA3, p300, CARM1 e SET7 a remodulação da cromatina; NFX1-91 a ativação da telomerase; STAT-1 e TLR-9 a evasão imune, ATR, BCRA1, MCM7, MGMT. XRCC1 a estabilidade genômica; DLG1, MAGI1-3, SCRIBBLE, paxilina e fibulina a perda de polaridade celular e indução de hiperplasia. No entanto, as consequências de muitas dessas interações não têm sido bem estudadas em queratinócitos primários humanos, a célula alvo natural do HPV. No presente estudo analizamos o efeito da proteína E6 de HPV16 (alto risco) e HPV11 (baixo risco) na expressão e na atividade de fatores envolvidos na regulação/execução de apoptose induzida pelas citocinas TNF e TRAIL e pelo quimioterápico Rapamicina. Através de ensaios de proliferação/viabilidade observamos que as células que expressam E6 de ambos os tipos virais apresentam resistência às citocinas e à rapamicina, quando comparadas a culturas controle. Além disso, observamos que as células que expressam E6 apresentam diferenças no padrão de expressão de proteínas envolvidas na regulação das vias extrínseca e intrínseca da apoptose. / The infection with oncogenic HPV types is the main risk factor for the development of cervical cancer, one of the most common malignancies in women worldwide. This group of viruses is also associated with a significant proportion of other anogenital cancer and head and neck tumor. High-risk HPV express two oncoproteins, E6 and E7, which act on specific cellular factors altering difefferent signaling pathways. For instance E6 oncoprotein is able to bind the p53 tumor suppressor protein and promote its degradation by the ubiquitin dependent proteolysis pathway. Furthermore, the interaction of E6 with various cellular proteins for example, E6AP, TNFR1, caspase 8 Bak and confers resistance to apoptosis; hADA3, p300, and CARM1 SET7 the reshaping of chromatin; NFX1-91 telomerase activation; STAT-1 and TLR-9 immune evasion, ATR, BCRA1, MCM7, MGMT. XRCC1 genomic stability; Dlg1, MAGI1-3, scribble, paxillin and fibulin loss of cell polarity and hyperplasia of induction. In the present study we analyzed the effect of the E6 protein of HPV (highrisk) and HPV11 (low-risk) on the expression and activity of factors involved in the regulation/execution of apoptosis induced by the cytokines TNF and TRAIL and the chemotherapeutic agent Ramaycin. Using proliferation/viability assays we observed that cells expressing E6 from either viral cytokines and Rapamycin when compared with control cells. Besides, we observed that cells expressing E6 exhibit differences in the expression pattern of protein involved in the regulation of apoptosis extrinsic and intrinsic pathways.

Submitted by Mariana Dornelles Vargas (marianadv) on 2015-05-29T17:36:45Z No. of bitstreams: 1 percepcao_sobre.pdf: 624117 bytes, checksum: 32c35c4fe3164fc8bd6f5aca246544df (MD5) / Made available in DSpace on 2015-05-29T17:36:45Z (GMT). No. of bitstreams: 1 percepcao_sobre.pdf: 624117 bytes, checksum: 32c35c4fe3164fc8bd6f5aca246544df (MD5) Previous issue date: 2012-05 / Nenhuma / Esta dissertação é composta por dois artigos, o primeiro deles de revisão sistemática da literatura e o segundo um artigo empírico. No estudo 1, buscou-se realizar uma revisão sistemática da literatura internacional sobre percepção da doença e o câncer. Foram encontrados 11 artigos. Os resultados mostraram que os estudos são diversos e o foco das pesquisas é abrangente, relacionando a percepção sobre a doença e o câncer em diversas situações, especialmente na qualidade de vida. No estudo 2, o objetivo foi avaliar e comparar as percepções sobre o câncer do colo do útero em três grupos de mulheres: 1) mulheres com diagnóstico de câncer do colo do útero e em tratamento para a doença; 2) mulheres com lesões precursoras de câncer uterino ou contaminadas pelo HPV; e 3) mulheres sem a doença e sem lesão precursora. Participaram da pesquisa 150 mulheres adultas em atendimento ambulatorial de ginecologia e ambulatório de oncologia em dois hospitais de Porto Alegre (RS). Foram utilizadas como instrumentos a ficha de Dados Sociodemográficos e Clínicos, o Questionário de percepção sobre a doença Revised Illness Perception Questionnaire (IPQ-R) e Revised Illness Perception Questionnaire for Healthy People (IPQ-RH). Os resultados mostraram diferenças na percepção entre os grupos nas dimensões identidade (F=11,654, p<0,001), duração cíclica da doença (F=4,416, p<0,05) e causas da doença (F=15,941; p<0,001), o que mostra que as mulheres saudáveis apresentaram percepções positivas em relação à doença, diferente das mulheres com lesão e com câncer. As percepções entre os três grupos se assemelharam nas seguintes dimensões: duração da doença (aguda/crônica), consequência da doença, controle pessoal e do tratamento, coerência da doença e representações emocionais. / This dissertation consists of two articles, the first one being a systematic review of the literature and the second an empirical study. In study 1, it sought to conduct a systematic review of international literature regarding the perception of the disease and the cancer itself. 11 articles were found. The results showed that the studies are diverse and the focus of research is comprehensive, listing the perception about the disease and the cancer in various situations, especially in terms of quality of life. In study 2, the objective was to evaluate and compare the perceptions about cervical cancer found in three groups of women: 1) women diagnosed with cervical cancer and undergoing treatment for the disease; 2) women with uterine early stage cancer lesions or with HPV infections; and 3) women not having the disease nor the early stage cancer lesions. 150 adult women participated in the study at clinical gynecology and oncology outpatient clinics in two hospitals in Porto Alegre (RS). as instruments, the Demographic and clinical data sheet, the Questionnaire of perception about the disease Revised Illness Perception Questionnaire (IPQ-R) and Revised Illness Perception Questionnaire for Healthy People (IPQ-RH) were used. The results showed differences in perception between the groups in the identity dimensions (F = p < 0.001 11.654,), cyclic duration of disease (F = 4.416, p < 0.05) and causes of disease (F = 15.941, p < 0.001), which shows that healthy women showed positive perceptions in relation to disease, different from women with cancer and lesions. Perceptions among the three groups resembled each other in the following dimensions: length of the disease (acute/chronic), as a result of illness, personal control and consistency of treatment, disease and emotional representations.