VanEenwyk J; Davis FG; Bowen PE
Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois, Chicago.
Int J Cancer (United States) Apr 22 1991, 48 (1) p34-8

A case-control study examined the association between cervical intra-epithelial neoplasia (CIN) and serum and dietary alpha-carotene, beta-carotene, cryptoxanthin, lutein, and lycopene. Cases (n = 102) had biopsy confirmed CIN I, II or III. Controls matched for age, ethnic origin and clinic (n = 102) had normal Pap smears. Participants completed health history and food frequency questionnaires. Fasting venous blood samples were assayed for serum carotenoids. Multivariable conditional logistic regression analyses yielded odds ratios and 95% confidence intervals (CIs) for those in quartiles 3, 2, and 1 (lowest) compared to quartile 4 (highest) of serum lycopene of 3.5 (1.1-11.5), 4.7 (1.2-17.7) and 3.8 (1.1-12.4), respectively. Similar analyses yielded adjusted odds ratios (ORaS) and 95% CIs of 4.6 (1.1-19.7), 5.8 (1.6-21.3) and 5.4 (1.3-23.3) for dietary intake of lycopene. The findings for lycopene-rich foods (tomatoes) were consistent with this result. CIN was not associated with the lutein. Findings for alpha-carotene, beta-carotene and cryptoxanthin were ambiguous. Quartile of vitamin C intake was also inversely associated with CIN with ORaS and 95% CIs of 3.7 (0.9-14.6), 4.1 (1.0-17.2), and 6.4 (1.4-30.0) for those in quartiles 3, 2, and 1 compared to quartile 4.

Romney SL; Duttagupta C; Basu J; Palan PR; Karp S; Slagle NS; Dwyer A; Wassertheil-Smoller S; Wylie-Rosett J
Am J Obstet Gynecol (United States) Apr 1 1985, 151 (7) p976-80

Plasma concentrations of vitamin C were determined in a case-control study of women (n = 80) who had sought a Papanicolaou test in the Bronx Municipal Hospital Center. Controls (n = 34) were women having negative cytologic tests, negative colposcopic findings, and no known gynecologic dysfunction. Cases (n = 46) were defined as women who had either one positive or two consecutive suspicious Papanicolaou smears in a 12-month period. The mean concentration of vitamin C in the plasma was significantly lower in the cases than in the controls (0.36 versus 0.75 mg/dl, p less than 0.0001). Cases were further stratified according to the histopathologic diagnosis. The data direct attention to a possible etiologic association of vitamin C in human cervical epithelial abnormalities. A clinical trial with vitamin C intervention is suggested.

Kantesky PA; Gammon MD; Mandelblatt J; Zhang ZF; Ramsey E; Dnistrian A; Norkus EP; Wright TC Jr
Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia 19104, USA
pkanetsk@cceb.med.upenn.edu
Nutr Cancer (United States) 1998, 31 (1) p31-40

We examined whether elevated levels of retinoids, carotenoids, folate , and vitamin E protected against cervical dysplasia among non-Hispanic, black women. We enrolled 32 women with incident cervical dysplasia , including cervical intraepithelial neoplasia (CIN) I, CIN II, and CIN III/carcinoma in situ, and 113 control women with normal cervical cytology in case-control study. Micronutrient levels were estimated from a food-frequency questionnaire (FFQ) and measured from blood samples. Information on risk factors for cervical neoplasia was elicited by interview. Hybrid capture was used to determine infection with human papillomavirus. After adjustment for potential confounders, analysis of micronutrient levels estimated from the FFQ suggested that women in the upper tertile of lycopene and vitamin A intake were one-third (odds ratio = 0.32, 95% confidence interval = 0.8-1.3) and one-fourth (odds ratio = 0.24, 95% confidence interval = 0.05-1.2) as likely, respectively, to have dysplasia as women in the lower tertile. Borderline protective trends (p < or = 0.10) were apparent. Elevated levels of serum lycopene also suggested some protection against dysplasia. Results were not significant at alpha = 0.05 because of the small number of case women enrolled. Overall, correlations between estimates from the FFQ and serum levels were poor. This study indicates that, among black women, lycopene and perhaps vitamin A may play a protective role in the early stages of cervical carcinogenesis.

Batieha AM; Armenian HK; Norkus EP; Morris JS; Spate VE; Comstock GW
Department of Epidemiology, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland 21205.
Cancer Epidemiol Biomarkers Prev (United States) Jul-Aug 1993, 2 (4) p335-9

A nested case-control study was conducted in Washington County, MD, to determine whether low serum micronutrients are related to the subsequent risk of cervical cancer. Among the 15,161 women who donated blood for future cancer research during a serum collection campaign in 1974, 18 developed invasive cervical cancer and 32 developed carcinoma in situ during the period January 1975 through May 1990. For each of these 50 cases, two matched controls were selected from the same cohort. The frozen sera of the cases and their matched controls were analyzed for a number of nutrients. The mean serum levels of total carotenoids, alpha-carotene, beta-carotene, cryptoxanthin, and lycopene were lower among cases than they were among controls. When examined by tertiles, the risk of cervical cancer was significantly higher among women in the lower tertiles of total carotenoids (odds ratio 2.7; 95% confidence limit, 1.1-6.4), alpha-carotene (odds ratio, 3.1; 95% confidence limit, 1.3-7.6), and beta-carotene (odds ratio, 3.1; 95% confidence limit, 1.2-8.1) as compared to women in the upper tertiles and the trends were statistically significant. Cryptoxanthin was significantly associated with a lower risk of cervical cancer when examined as a continuous variable. Retinol, lutein, alpha- and gamma-tocopherol, and selenium were not related to cervical cancer risk. Smoking was also strongly associated with cervical cancer. These findings are suggestive of a protective role for total carotenoids, alpha-carotene and beta-carotene in cervical carcinogenesis and possibly for cryptoxanthin and lycopene as well.

Volz J.; Van Rissenbeck A.; Blanke M.; Melchert F.; Schneider A.; Biesalski H.K.
OA Universitats-Frauenklinik, Theodor-Kutzer-Ufer 10,68135 Mannheim Germany
Zentralblatt fur Gynakologie (Germany) 1995, 117/9 (472-475)

In 34 patients with HVP-infection of the cervix and in 40 patients with CIN III standardised biopsies were taken from the involved area and normal cervical epithelium for determination of the local concentration of retinylester. In all cases diagnosis was confirmed colposcopically, cytologically and by histology. HPV infection was confirmed by in situ hybridisation. Determination of retinylester was performed by HPLC. No significant difference of local retinyl-palmitate concentration was detectable in HPV infected versus normal tissue. Retinyl-palmitate concentration was extremely lower in CIN III compared with normal cervical epithelium and HPV-infected tissue. The determination of plasma level of retinol showed no significant difference between the two groups. So it can be presumed that the reduction of retinyl-palmitate in CIN III is a local process and a local supplementation of Vitamin A might contribute to the prevention of cervical neoplasia.

Kelly GS
gregnd@worldnet.att.net
Altern Med Rev (United States) Jun 1998, 3 (3) p208-20

Folates function as a single carbon donor in the synthesis of serine from glycine, in the synthesis of nucleotides form purine precursors, indirectly in the synthesis of transfer RNA, and as a methyl donor to create methylcobalamin, which is used in the re-methylation of homocysteine to methionine. Oral folates are generally available in two supplemental forms, folic and folinic acid. Administration of folinic acid bypasses the deconjugation and reduction steps required for folic acid . Folinic acid also appears to be a more metabolically active form of folate , capable of boosting levels of the coenzyme forms of the vitamin in circumstances where folic acid has little to no effect. Therapeutically, folic acid can reduce homocysteine levels and the occurrence of neural tube defects, might play a role in preventing cervical dysplasia and protecting against neoplasia in ulcerative colitis, appears to be a rational aspect of a nutritional protocol to treat vitiligo, and can increase the resistance of the gingiva to local irritants, leading to a reduction in inflammation. Reports also indicate that neuropsychiatric diseases secondary to folate deficiency might include dementia, schizophrenia-like syndromes, insomnia, irritability, forgetfulness, endogenous depression, organic psychosis, peripheral neuropathy, myelopathy, and restless legs syndrome. (103 Refs.)

Zarcone R.; Bellini P.; Carfora E.; Vicinaza G.; Raucci F.
Via Cappuccini, 16,Montesarchio (BN) Italy
Minerva Ginecologica (Italy) 1996, 48/10 (397-400)

The localized folate deficiency, which is sometimes misdiagnosed as cervical dysplasia, because of morphologic similarities between the cytologic features of megaloblastosis seen with folate deficiency and the changes associated with dysplasia, could be a component of the dysplastic process. In this study we attempted the effect of oral folic in women with cervical dysplasia . A total of 154 subjects with grade 1 or 2 CIN were randomly assigned either 10 mg of folic acid or a placebo daily for 6 months. Clinical status, human papillomavirus type 16 infection and blood folate levels were monitored at 2 month intervals. After 6-months no significant differences were observed between supplemented and unsupplemented subjects regarding dysplasia status, biopsy results, or prevalence of human papillomavirus type 16 infection. Folate deficiency may be involved as a cocarginogen during the initiation of cervical dysplasia , but folic acid supplements do not alter the course of estabilished disease.

Butterworth Jr. C.E.
Dept. of Nutrition Sciences, University of Alabama,Birmingham, AL 35294 United States
Journal of the American College of Nutrition (United States) 1993, 12/4 (438-441)

Key observations by Dr. Lucy Wills 65 years ago have led to the identification of folate as a nutrient essential for the prevention of megaloblastic anemia of pregnancy. The more recently discovered relationships of folate status to cervical dysplasia , neural tube defects, and atherosclerosis are reviewed here.

Ziegler RG
Adv Exp Med Biol (United States) 1986, 206 p11-26

Epidemiologic studies of the relationships between vitamins and 3 types of cancer are reviewed. First, the widely reported association between vitamin A and beta -carotene and risk of lung cancer is considered. In a large population-based case-control study of lung cancer among white males in New Jersey, increased intake of vegetables, dark green vegetables, dark yellow-orange vegetables, and carotenoids were each associated with reduced risk, but intake of retinol or total vitamin A was not related. The protective effect of vegetables was limited to current and recent cigarette smokers, which suggests that vegetable intake prevents a late-stage event in carcinogenesis. Consumption of dark yellow-orange vegetables was consistently more predictive of reduced risk than either the total carotenoid index or consumption of any other food group, possible because of the high content of beta -carotene in this food group. The results and limitations of other epidemiologic studies of diet and lung cancer are reviewed. Second, the evolving relationship between multiple micronutrient deficiencies and esophageal cancer is discussed. In a death certificate-based case-control study of esophageal cancer in black males in Washington, D.C., several indicators of general nutritional status, including consumption of fresh or frozen meat and fish, dairy products and eggs, and fruit and vegetables, and the number of meals eaten per day, were inversely and independently correlated with the risk of esophageal cancer. Estimates of intake of micronutrients, such as carotenoids, vitamin C , thiamin, and riboflavin, were less strongly associated with reduced risk than were the broad food groups that provide most of each micronutrient. Thus no single micronutrient deficiency was identified. Other studies suggest that generally poor nutrition may partially explain the susceptibility of urban black men to esophageal cancer. Finally, the postulated association between low folacin levels and risk of cervical cancer is examined. Among women who use oral contraceptives, serum and red blood cell folacin levels were reported to be lower among those with cervical dysplasia . In a clinical trial involving oral contraceptive users, cervical dysplasia gradually decreased in the group supplemented with oral folate but remained unchanged in the group given the placebo. Other epidemiologic studies of diet and cervical cancer are discussed.

Butterworth Jr. C.E.; Hatch K.D.; Macaluso M.; Cole P.; Sauberlich H.E.; Soong S.-J.; Borst M.; Baker V.V.
Nutrition Sciences Department, University of Alabama, UAB Station,Birmingham, AL 35294-3360 United States
Journal of the American Medical Association 1992, 267/4 (528-533)

Objective. - To test the hypothesis that nutritional deficiency affects the incidence of cervical dysplasia in young women.

Design and Setting. - Case-control study. Participants were derived from community family-planning clinics and referrals to a colposcopy center.

Participants. - A total of 726 subjects were screened, yielding 294 cases of dysplasia and 170 controls defined by coexistent cytologic and colposcopic evidence.

Main Outcome Measures. - Planned prior to data collection. Odds ratios were computed using logistic regression models to evaluate association between cervical dysplasia and sociodemographic, sexual, and reproductive factors; smoking; oral contraceptive use; human papillomavirus (HPV) infection; and 12 nutritional indices determined by blind analysis of nonfasting blood specimens.

Results. - The number of sexual partners, parity, oral contraceptive use, and HPV-16 infection were significantly associated with cervical dysplasia . Plasma nutrient levels were generally not associated with risk. However, red blood cell folate levels at or below 660 nmol/L interacted with HPV-16 infection. The adjusted odds ratio for HPV-16 was 1.1 among women with folate levels above 660 nmol/L but 5.1 (95% confidence interval, 2.3 to 11) among women with lower levels. Interactions of red blood cell folate levels with cigarette smoking and parity were also present but were not statistically significant.

Conclusion. - Low red blood cell folate levels enhance the effect of other risk factors for cervical dysplasia and, in particular, that of HPV-16 infection.

Grio R; Piacentino R; Marchino GL; Navone R
Department of Gynecology and Obstetrics, University of Turin, Italy.
Panminerva Med (Italy) Dec 1993, 35 (4) p193-6

The authors made a study on 90 patients affected by various degrees of uterine cervix dysplasia searching for folic acid plasmatic concentrations. The team members affected by CIN have been compared with a test team consisting of women with normal pap-test and vaginoscopy. The study proved that the average levels of folic acids have significantly decreased in cases of dysplasia compared with the test team. These results allow stating that low folic acid plasmatic concentrations may be associated with cervix neoplasms development.

Zarcone R; Bellini P; Carfora E; Vicinanza G; Raucci F
Istituto di Ginecologia ed Ostetricia, II Universita degli Studi, Napoli.
Minerva Ginecol (Italy) Oct 1996, 48 (10) p397-400

The localized folate deficiency, which is sometimes misdiagnosed as cervical dysplasia , because of morphological similarities between the cytologic features of megaloblastosis seen with folate deficiency and the changes associated with dysplasia, could be a component of the dysplastic process. In this study we attempted the effect of oral folic in women with cervical dysplasia . A total of 154 subjects with grade 1 or 2 CIN were randomly assigned either 10 mg of folic acid or a placebo daily for 6 months. Clinical status, human papillomavirus type 16 infection and blood folate levels were monitored at 2 month intervals. After 6-months no significant differences were observed between supplemented and unsupplemented subjects regarding dysplasia status, biopsy results, or prevalence of human papillomavirus type 16 infection. Folate deficiency the initiation of cervical dysplasia , but folic acid supplements do not alter the course of established disease.

Christensen B Seksjon for farmakologi Institutt for klinisk biologi Universitetet i Bergen.
Tidsskr Nor Laegeforen (Norway) Jan 20 1996, 116 (2) p250-4

The biochemical role of folate is in the interconversion of one-carbon units in intermediary metabolism; a process in which a methyl group is formed de novo. The methyl group is subsequently transferred to adenosylmethionine, which is an important methyl donor in the methylation of DNA. A negative correlation exists between the intake of folate in pregnancy and the occurrence of neural tube defects and certain malignant brain tumours in children. Numerous clinical studies have pointed to an association between folate status in adults and both the occurrence of cancer and the premalignant changes, cervical dysplasia , bronchial metaplasia, and colorectal adenomas. Folate deficiency may cause chromosomal damage, due to impaired DNA synthesis or repair. Moreover, decreased production of adenosylmethionine may influence the expression of developmental genes and of oncogenes and/or tumour suppressor genes through disturbed methylation of DNA. (45 Refs.)

Butterworth Jr. C.E.; Hatch K.D.; Soong S.-J.; Cole P.; Tamura T.; Sauberlich H.E.; Borst M.; Macaluso M.; Baker V.
Department of Nutrition, Sciences, University of Alabama,Birmingham, AL 35294-3360 United States
American Journal of Obstetrics and Gynecology 1992, 166/3 (803-809)

Objective: We attempted to evaluate the effect of oral folic acid supplementation on the course of cervical dysplasia .

Study design: A total of 235 subjects with grade 1 or 2 cervical intraepithelial neoplasia were randomly assigned to receive either 10 mg of folic acid or a placebo daily for 6 months. Clinical status, human papillomavirus type 16 infection, and blood folate levels were monitored at 2-month intervals. Outcome data were subjected to chisup 2 analysis.

Results: The prevalence of human papillomavirus type 16 infection initially was 16% among subjects in the upper tertile of red blood cell folate versus 37% in the lower tertile (trend p = 0.035). After 6 months no significant differences were observed between supplemented and unsupplemented subjects regarding dysplasia status, biopsy results, or prevalence of human papillomavirus type 16 infection.

Conclusion: Folate deficiency may be involved as a cocarcinogen during the initiation of cervical dysplasia , but folic acid supplements do not alter the course of established disease.

Fowler BM; Giuliano AR; Piyathilake C; Nour M; Hatch K
Arizona Cancer Center, University Medical Center, University of Arizona, Tucson 85716, USA.
Cancer Epidemiol Biomarkers Prev Oct 1998, 7 (10) p901-6

We have shown previously that DNA hypomethylation is significantly associated with grade of cervical intraepithelial neoplasia (CIN; Y.I. Kim et al., Cancer, 74: 893-899, 1994). The objective of this study was to further describe this relationship and to investigate the role of folate in the observed association of DNA hypomethylation and CIN. Eighty-three patients with abnormal PAP smear results were referred to the Cervical Dysplasia Clinic at the University of Arizona for colposcopic examination and biopsy. Patients completed a short questionnaire and provided a nonfasting serum sample. DNA hypomethylation was assessed by incubating DNA extracted from biopsy samples with [3H]methyl-S-adenosylmethionine and Sss 1 methylase. Cervical tissue and serum folate concentrations were assessed using a microbiological assay. All folate levels were log transformed prior to statistical analysis. The histological distribution of the samples was: 7 adjacent normal, 30 CIN I, 18 CIN II, 13 CIN III, and 11 carcinoma in situ (CIS). The mean age of participants was 29.8 +/- 9.6 years. DNA hypomethylation was significantly different between select histological levels. Both cervical tissue folate and serum folate levels were significantly correlated to methylation level (P = 0.0211 and P = 0.0569, respectively). Smoking, hormonal contraceptive use, parity, and human papillomavirus infection were not associated with DNA hypomethylation or folate status. The current use of vitamins was significantly associated with serum folate level but not with methylation or cervical folate levels. These data extend our earlier findings that DNA hypomethylation is an early event in cervical carcinogenesis. To conclude that the folate level is significantly related to DNA hypomethylation, further investigation of DNA hypomethylation of specific genes is required.

Butterworth CE Jr; Hatch KD; Gore H; Mueller H; Krumdieck CL
Am J Clin Nutr (United States) Jan 1982, 35 (1) p73-82

Forty-seven young women with mild or moderate dysplasia of the uterine cervix (cervical intraepithelial neoplasia) diagnosed by cervical smears, received oral supplements of folic acid, 10 mg, or a placebo (ascorbic acid, 10 mg) daily for 3 months under double-blind conditions. All had used a combination-type oral contraceptive agent for at least 6 months and continued it while returning monthly for follow-up examinations. All smears and a biopsy obtained at the end of the trial period were classified by a single observer without knowledge of treatment status using an arbitrary scoring system (1 normal, 2 mild, 3 moderate, 4 severe, 5 carcinoma in situe). Mean biopsy scores from folate supplemented subjects were significantly better than in folate-unsupplemented subjects (2.28 versus 2.92, respectively; p less than 0.05). Final versus initial cytology scores were also significantly better in supplemented subjects (1.95 versus 2.32, respectively; p less than 0.05), unchanged in patients receiving the placebo (2.27 versus 2.30, respectively). Before treatment the mean red cell folate concentration was lower among oral contraceptive agent users than nonusers (189 versus 269 ng/ml, respectively; p less than 0.01) and even lower among users with dysplasia (161 versus 269 ng/ml, respectively; p less than 0.001). Morphological features of megaloblastosis were associated with dysplasia and also improved in folate supplemented subjects. These studies indicate that either a reversible, localized derangement in folate metabolism may sometimes be misdiagnosed as cervical dysplasia, or else such a derangement is an integral component of the dysplastic process that may be arrested or in some cases reversed by oral folic acid supplementation.

Whitehead N; Reyner F; Lindenbaum J
Harlem Hospital, Lenox Avenue and 135th Street, New York, New York 10037
J. Am. Med. Assoc.; Vol 226 Iss Dec 17 1973, P1421-1424, (Ref 20)

ASHP Megaloblastic abnormalities of cervicovaginal cells similar to those seen in severe folate and vitamin B12 deficiency were found in 22 (19%) of 115 women taking oral contraceptive agents (combined estrogen-progestogen or progestogens only). Similar changes were not observed in any of 51 controls not taking these medications. The cytologic abnormalities could not be related to hematologic findings or serum folate and vitamin B12 concentrations. The changes reverted to normal or improved markedly in all 8 patients treated with pharmacologic doses of folic acid for 3 weeks. It is hypothesized that oral contraceptive agents induce a localized interference with folate metabolism at the end organ level.

Kornberg A; Segal R; Theitler J; Yona R; Kaufman S
Dep Hematol., Assaf Harofeh Med. Cent., 70300 Zerifin.
Isr J Med Sci 25 (3). 1989. 142-145. Israel Journal of Medical Sciences

A 34-year-old women developed megaloblastic anemia and peripheral polyneuropathy following the use of oral contraceptives for 4 years. Low levels of folic acid and vitamin B12 were found. Both the complete recovery after therapy with the vitamins, and the absence of other causes of vitamin B12 and folate deficiency , suggest that the vitamin deficiencies were caused by the oral contraceptives and resulted in the rare combination of megaloblastic anemia and polyneuropathy. The poor response to vitamin B12 alone, and the development of anemia and polyneuropathy 4 months after cessation of vitmain B12 therapy suggest that folate deficiency was the primary problem.

Green JD
South Med J; Vol 68, Iss 2, 1975, P249-50

A case is reported of megaloblastic anemia resulting from folate deficiency in a vegetarian who had been taking oral contraceptives for eight years. A brief report of the pertinent literature is included.

Streiff RR
Veterans Administration Hospital and the College of Medicine, University of Florida, Gainesville, Florida
reprints: AMA Department of Foods and Nutrition, 535 N. Dearborn Street, Chicago, Illinois 60610
J. Am. Med. Assoc.; Vol 214 Iss Oct 5 1970, P105-108, (Ref 38)

ASHP The report concerns 7 cases of folate deficiency and anemia apparently due to orally administered contraceptives and studies on the effect of this type of medication on folate absorption.

Wylie-Rosett J.A.; Romney S.L.; Slagle N.S.; et al.
Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, Bronx, NY 10461 United States
Nutrition and Cancer (United States) 1984, 6/1 (49-57)

A case-control study was undertaken to determine the dietary intake of vitamin A in women having abnormal uterocervical cytology. The study groups (87 cases and 82 controls) were drawn from a population of women who received a screening Pap test in the ambulatory health care section of a large municipal hospital center. A subset of cases (with abnormal cytology) were matched to controls for age, ethnicity, socioeconomic status, and parity. Nutrient intake and retinol binding protein concentrations were determinde; epidemiological data were also obtained. It was found that the subset of cases with severe dysplasia or carcinoma in situ (CIS) were more likely to have a total dietary vitamin A intake below the pooled median (3,450 IU) and/or a beta-carotene intake below the pooled median (2,072 IU) than were normal controls (p<0.05 and p<0.025, respectively). Odds ratios revealed approximately a 3-fold greater risk for severe dysplasia or CIS in women with lowered vitamin A or beta-carotene intake. In addition, retinol binding protein was either absent or undetectable in 78.8% of the dysplastic tissue samples, versus 23.5% of the normal tissue samples (p<0.005).

Meyskens Jr. F.L.; Surwit E.; Moon T.E.; Childers J.M.; Davis J.R.; Dorr R.T.; Johnson C.S.; Alberts D.S.
Irvine Clinical Cancer Center, University of California, 101 The City Dr.,Orange, CA 92668 United States
Journal of the National Cancer Institute (United States) 1994, 86/7 (539-543)

Background: Retinoids enhance differentiation of most epithelial tissues. Epidemiologic studies have shown an inverse relationship between dietary intake or serum levels of vitamin A and the development of cervical dysplasia and/or cervical cancer. Pilot and phase I investigations demonstrated the feasibility of the local delivery of all-trans-retinoic acid (RA) to the cervix using a collagen sponge insert and cervical cap. A phase II trial produced a clinical complete response rate of 50%.

Purpose: This randomized phase III trial was designed to determine whether topically applied RA reversed moderate cervical intraepithelial neoplasia (CIN) II or severe CIN.

Methods: Analyses were based on 301 women with CIN (moderate dysplasia, 151 women; severe dysplasia, 150 women), evaluated by serial colposcopy, Papanicolaou cytology, and cervical biopsy. Cervical caps with sponges containing either 1.0 mL of 0.372% beta-trans-RA or a placebo were inserted daily for 4 days when women entered the trial, and for 2 days at months 3 and 6. Patients receiving treatment and those receiving placebo were similar with respect to age, ethnicity, birth-control methods, histologic features of the endocervical biopsy specimen and koilocytotic atypia, and percentage of involvement of the cervix at study. Treatment effects were compared using Fisher's exact test and logistic regression methods. Side effects were recorded, and differences were compared using Fisher's exact test.

Results: RA increased the complete histologic regression rate of CIN II from 27% in the placebo group to 43% in the retinoic acid treatment group (P = .041). No treatment difference between the two arms was evident in the severe dysplasia group. More vaginal and vulvar side effects were seen in the patients receiving RA, but these effects were mild and reversible.

Conclusions: A short course of locally applied RA can reverse CIN II, but not more advanced dysplasia, with acceptable local side effects. Implications: A derivative of vitamin A can reverse or suppress an epithelial preneoplasia, lending further support to the notion that chemoprevention of human cancer is feasible.

Graham V.; Surwit E.S.; Weiner S.; Meyskens Jr. F.L.
Departments of Medicine, Obstetrics and Gynecology, University of Arizona Health Sciences Center, Tucson, AZ 85724 United States
Western Journal of Medicine (United States) 1986, 145/2 (192-195)

Retinoids are effective suppressors of the phenotypic development of cancer in many animal systems, whether the process is initiated by chemical, physical or viral carcinogens. Cases of cervical intraepithelial neoplasia are excellent for studying the effectiveness of retinoids as chemopreventive agents because the process can be closely followed by serial colposcopic and pathologic (cytology or biopsy) means and changes in the condition safely monitored. We have previously conducted a phase I study of trans-retinoic acid (Tretinoin) given topically by a collagen sponge and cervical cap. A dose of 0.372% was selected for phase II trial . We have treated 20 patients with topical retinoic acid, and a complete response with total regression of disease was obtained in 50%. Systemic and cervical side effects were mild and vaginal side effects moderate but tolerable. These results provide a clinical basis for a randomized, double-blind phase III study to definitely answer the question of whether retinoic acid is an effective chemopreventive agent for cervical cancer.

Weiner SA; Surwit EA; Graham VE; Meyskens FL Jr
Invest New Drugs 1986, 4 (3) p241-4

Forty-two patients were entered into a phase I trial to evaluate the vitamin A derivative, trans-retinoic acid, in cervical intraepithelial neoplasia. Treatment consisted of four consecutive 24-h applications of retinoids via an inert collagen sponge in a cervical cap. Patients were followed for response at 3-month intervals using cytology, colposcopy, and selected biopsies. Thirty-six patients were evaluable (mild dysplasia, 13; moderate dysplasia, 17; severe dysplasia, 6) with follow-up from 5 to 18 months. Complete regression was seen in 2/14 (14%) patients treated with concentrations of 0.05%----0.1167% and in 10/22 (45%) patients treated with concentrations of 0.1583%----0.484% (p less than 0.05). One patient with negative biopsies at 12 months has subsequently recurred at 18 months.

Romney SL; Palan PR; Duttagupta C; Wassertheil-Smoller S; Wylie J; Miller G; Slagle NS; Lucido D
Am J Obstet Gynecol (United States) Dec 15 1981, 141 (8) p890-4

Women with abnormal cytology were matched with normal control subjects for age, parity, ethnicity, and socioeconomic class and participated in a blind case-control study focused on the role of nutrition in cervical dysplasia . Sucrose gradient ultracentrifugation studies for determination of the presence and concentration of the binding proteins for retinol and retinoic acid were performed on colposcopic biopsy tissue specimens. The nutritional survey revealed statistically significant differences for vitamins A and C and beta carotene . Retinol binding protein was absent or minimally detectable and inversely related to the severity of the dysplasia. It is proposed that a double-blind clinical trial be conducted to evaluate whether retinoids may pharmacologically inhibit, arrest, or reverse cervical dysplasia .

Niles RM
Department of Biochemistry and Molecular Biology, Marshall University School of Medicine, Huntington, WV 25755, USA.
Adv Exp Med Biol 1995, 375 p1-15

Vitamin A is metabolized to several biologically active compounds, the best known of which is retinoic acid. This compound has been shown to inhibit the growth of a variety of tumor cells and to induce a more differentiated phenotype in several tumor types. Vitamin D is metabolized to the active compound 1,25-dihydroxyvitamin D3. This vitamin is well-known for its role in maintaining calcium homeostasis in the body. Recently it has been shown that vitamin D3 can also inhibit tumor cell replication and stimulate differentiation of selected tumor types. Retinoic acid is being used clinically to treat promyelocytic leukemia, head and neck tumors as well as cervical dysplasia . Use of vitamin D3 clinically has been restricted by its affect on calcium metabolism. Recently, however, new analogs of vitamin D3 have been developed which have much less calcium mobilizing activity, yet still retain their tumor inhibitory properties. The action of both of these vitamins is mediated by nuclear receptors which have the same structure as steroid receptors. There are three nuclear retinoic acid receptors (RAR alpha, beta, and gamma), but only one vitamin D3 nuclear receptor. These receptors are expressed in very small amounts. Since the ligand should be in vast excess of receptor (ie not limiting), we explored the possibility that response to vitamin A might be mediated by control of RAR expression. Using B16 mouse melanoma cells as a model system, we found that RAR alpha and gamma mRNAs were constitutively expressed. RAR beta mRNA was induced by treatment of the cells with RA. Induction of RAR beta mRNA occurred within 1h and was not inhibited by cycloheximide. The mRNA for all three RARs was dramatically decreased with 8-bromo-cyclic AMP treatment and could not be rescued by addition of RA. Analysis of RAR gamma revealed that this decrease occurred within 1h of exposure to 8-bromo-cyclic AMP and was not blocked by simultaneous treatment with cycloheximide. Nuclear extracts from cyclic AMP-treated cells showed a large decrease in protein binding to a retinoic acid response element (RARE) oligonucleotide compared to control cells. This correlated with a marked reduction of RA-stimulated RARE-reporter gene activity in transfected cells which were treated with cyclic AMP. Pre-treatment of B16 cells with cyclic AMP prior to RA addition dramatically reduced induction of PKC alpha, an early marker of RA-induced cell differentiation. Thus, cyclic AMP can antagonize the physiological actions of RA via its ability to inhibit RAR expression.

Darwiche N; Celli G; De Luca LM
Differentiation Control Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892.
Endocrinology May 1994, 134 (5) p2018-25

Retinoids are powerful regulators of epithelial differentiation and are essential for its maintenance. Because retinoids are necessary for cervical epithelial differentiation, they have been used as chemopreventive agents of cervical dysplasia and neoplasia. We were interested in determining whether different cervical epithelial phenotypes express specific retinoid receptors. The cervical epithelium contains the two phenotypes, stratified squamous and simple columnar, which join at the squamocolumnar junction. In addition, the simple columnar epithelium undergoes squamous metaplasia in response to vitamin A deficiency. Therefore, the cervical epithelium is suitable to study the expression pattern of the retinoid receptors in the three phenotypes, simple columnar, stratified squamous, and squamous metaplastic, simultaneously. The distribution pattern of the major retinoic acid receptor (RAR) isoforms (alpha 1, alpha 2, beta 2, beta 3, gamma 1, and gamma 2) and retinoid-X receptors (RXR alpha, -beta, and -gamma) was studied by in situ hybridization. At the tissue level, RAR alpha (1 and 2) and RXR (alpha and beta) transcripts and, to a lesser extent, RAR gamma (1 and 2) transcripts were associated with the cervical stratified squamous subjunctional epithelium. The simple columnar epithelium, which is highly responsive to vitamin A status, expressed high levels of RAR alpha (1 and 2), RAR beta (2 and 3), and RXR (alpha and beta) transcripts. Only RAR beta (2 and 3) and RXR (alpha and beta) transcripts were down-modulated by the condition of vitamin A deficiency and expressed less in squamous metaplastic foci than the simple columnar epithelium. RXR gamma was undetectable in all three cervical epithelia. At the cellular level, basal and suprabasal expression was found for RARs, and preferential localization of RXRs was seen in basal cells. RXRs are auxiliary proteins for a variety of other nuclear receptors with which they form heterodimers, including RARs. The fact that RXRs are mainly localized in basal and columnar cells of the cervix suggests the need for the regulation and diversity generated by potential heterodimeric interactions in these rapidly proliferating cells in vivo. The unique pattern of expression and localization of the RARs and RXRs in different cervical epithelial tissues and cell types supports the hypothesis that they perform specific functions in cervical epithelial differentiation. This is in contrast to the major isoforms of each RAR, which have similar patterns of expression in the different cervical epithelial phenotypes and cell types, suggesting a redundancy in function.

Meyskens FL
J Am Acad Dermatol Apr 1982, 6 (4 Pt 2 Suppl) p824-7

Investigation of retinoids for anticancer activity in humans, either in the chemopreventive or treatment mode, has been little studied. We summarize here our ongoing investigations in four different areas: (1) secondary prevention of cervical dysplasia with topical application of all-trans-retinoic acid; (2) adjuvant treatment of resected high-risk stage I and II malignant melanoma with bacille Calmette Guerin (BCG) plus or minus oral vitamin A ; (3) topical vitamin A acid therapy for cutaneous metastatic melanoma; an (4) oral isotretinoin as an anticancer agent.

Giuliano AR; Papenfuss M; Nour M; Canfield LM; Schneider A; Hatch K
Arizona Cancer Center, University of Arizona, Tucson 85724, USA
minority@azcc.arizona.edu
Cancer Epidemiol Biomarkers Prev Nov 1997, 6 (11) p917-23

Research from the past several years has definitively shown intermediate and high risk-type human papillomavirus (HPV) infection to play a significant role in cervical carcinogenesis. Persistent compared with intermittent infection appears to confer an elevated risk, and cofactors may be necessary to allow the virus to progress to cervical cancer. We explored the association between circulating concentrations of the antioxidant nutrients (alpha- and beta-carotene, lutein, lycopene, beta-cryptoxanthin, alpha-tocopherol, gamma-tocopherol, and ascorbate) and persistent HPV infection among 123 low-income Hispanic women who were all nonsmokers and were not currently using vitamin and mineral supplements. In addition, the association between these nutrients and grade of cervical pathology, independent of HPV status, was assessed. Intermediate and high risk-type HPV infection was assessed by the Digene Hybrid Capture System at two time points, 3 months apart. At the second interview, cytology, colposcopy, and a fasting blood draw were conducted. Mean concentrations of serum and plasma antioxidant nutrients were calculated within categories of HPV status (two times HPV negative, one time HPV positive, and two times HPV positive) and colposcopy. Adjusted mean concentrations of serum beta-carotene, beta-cryptoxanthin, lutein, and alpha- and gamma-tocopherol were on average 24% (P < 0.05) lower among women two times HPV positive compared with either two times HPV negative or one time HPV positive. Independent of HPV status, alpha-tocopherol was significantly inversely associated with grade of cervical dysplasia (normal, 21.57 microM; cervical intraepithelial neoplasia III, 17.27 microM). The results obtained in this study need to be confirmed in larger cohort studies with a longer follow-up period.

Kwasniewska A; Tukendorf A; Semczuk M
Department of Obstetrics and Gynecology, Medical Academy, Lublin, Poland.
Arch Immunol Ther Exp (Warsz) (Poland) 1996, 44 (5-6) p309-13

Studies were carried out in 528 women hospitalized in the Department of Obstetrics and Gynecology Medical Academy in Lublin. Besides the control group, patients were classified according to the observed histopathological changes in the cervix (CIN) and found infections with human papillomavirus (HPV). In all cases beta -carotene content in blood serum was examined. HPV infection was probably a cause of decrease of beta -carotene content. It was found that with increased advancement of cervical dysplasia the level of beta carotene in serum decreased.

Singh VN; Gaby SK
Department of Clinical Nutrition, Hoffmann-La Roche, Inc., Nutley, NJ 07110-1199.
Am J Clin Nutr Jan 1991, 53 (1 Suppl) p386S-390S

Epidemiological studies have shown that diets rich in one or more antioxidant nutrients may reduce the risk of cancers of the lung, uterine cervix, mouth, and gastrointestinal tract. Study of premalignant lesions offers a comparatively expedient approach to identifying and evaluating the efficacy of the cancer chemopreventive components of foods. Some recent findings suggest roles for beta-carotene and/or vitamin C in reversing or reducing the risk of cervical dysplasia and oral leukoplakia. There are some indications that vitamin C and beta-carotene may reduce the risk of atrophic gastritis and gastric cancer. Additional epidemiological and molecular biology studies and clinical intervention trials using premalignant lesions as the marker of specific cancer risks should become an important component of future research in the area of cancer chemoprevention. (57 Refs.)

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