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Multicenter Study
. 2009 Sep 1;101(5):865-70.
doi: 10.1038/sj.bjc.6605224. Epub 2009 Aug 4.

Differences in the risk of cervical cancer and human papillomavirus infection by education level

S Franceschi  1 , M Plummer, G Clifford, S de Sanjose, X Bosch, R Herrero, N Muñoz, S Vaccarella; International Agency for Research on Cancer Multicentric Cervical Cancer Study Groups; International Agency for Research on Cancer Human Papillomavirus Prevalence Surveys Study Group
Collaborators, Affiliations
Multicenter Study

Differences in the risk of cervical cancer and human papillomavirus infection by education level

S Franceschi et al. Br J Cancer. .

Abstract

Background: Cervical cancer risk is associated with low education even in an unscreened population, but it is not clear whether human papillomavirus (HPV) infection follows the same pattern.

Methods: Two large multicentric studies (case-control studies of cervical cancer and HPV prevalence survey) including nearly 20 000 women. GP5+/GP6+ PCR was used to detect HPV.

Results: Education level was consistently associated with cervical cancer risk (odds ratio (OR) for 0 and >5 years vs 1-5 years=1.50, 95% confidence interval (CI): 1.25-1.80 and 0.69, 95% CI: 0.57-0.82, respectively, P for trend <0.0001). In contrast, no association emerged between education level and HPV infection in either of the two IARC studies. A majority of the women studied had never had a Pap smear. The association between low education level and cervical cancer was most strongly attenuated by adjustment for age at first sexual intercourse and first pregnancy. Parity and screening history (but not lifetime number of sexual partners, husband's extramarital sexual relationships, and smoking) also seemed to be important confounding factors.

Conclusion: The excess of cervical cancer found in women with a low socio-economic status seems, therefore, not to be explained by a concomitant excess of HPV prevalence, but rather by early events in a woman's sexually active life that may modify the cancer-causing potential of HPV infection.

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Figures

Figure 1
Figure 1
Distribution of women with and without cervical cancer in the International Agency for Research on Cancer case–control studies and human papillomavirus prevalence surveys, according to education level, Pap smear history*, and study area. *In case–control studies, Pap smears taken 12 months before enrolment are excluded. †Study areas in Vietnam. ‡Study areas in Thailand. §Study areas in China.
Figure 2
Figure 2
Odds ratios (OR)† and corresponding 95% confidence intervals (CI) for (A) cervical cancer risk and (B) human papillomavirus (HPV) positivity among control women only. The International Agency for Research on Cancer Multicentric Case–Control Study. FSE=floating standard error, HPV=human papillomavirus. †Adjusted for age, study area, lifetime number of sexual partners, age at first sexual intercourse, husbands' extramarital sexual relationships, parity, age at first pregnancy, oral contraceptive use, and history of Pap smear.
Figure 3
Figure 3
Odds ratios (OR)† and corresponding 95% confidence intervals (CI) for human papillomavirus (HPV) positivity by education level. The International Agency for Research on Cancer HPV Prevalence Surveys. FSE=floating standard error. †Adjusted for age, study area, lifetime number of sexual partners, age at first sexual intercourse, husbands' extramarital sexual relationships and history of Pap smear.
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