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Adolescent characteristics and incidence of pre-malignant disease and invasive tumors of the cervix
  1. Lital Keinan Boker1,2,
  2. Gilad Twig3,4,
  3. Vered Klaitman-Meir3,
  4. Estela Derazne3,5,
  5. Avi Shina3,
  6. Hagai Levine4 and
  7. Jeremy D Kark4
  1. 1 Israel Center for Disease Control, Israel Ministry of Health, Ramat Gan, Israel
  2. 2 School of Public Health, University of Haifa, Haifa, Israel
  3. 3 Medical Corps, Israel Defense Forces, Tel Aviv, Israel
  4. 4 School of Public Health, Hebrew University of Jerusalem, Jerusalem, Israel
  5. 5 Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
  1. Correspondence to Professor Lital Keinan Boker, Israel Center for Disease Control, Israel Ministry of Health, Ramat Gan 52621, Israel; lital.keinan2{at}


Introduction Pre-malignant cervical disease and invasive cervical cancer present a significant global health burden with respect to morbidity and mortality, mostly in low- and middle-income countries. Human papillomavirus (HPV) infection typically manifests for the first time in adolescence. We aimed to identify adolescent sociodemographic and anthropometric characteristics associated with subsequent risk for pre-malignant cervical disease and cervical cancer, in a country that offers free screening and HPV vaccines.

Methods This historical cohort study included 969 123 Israeli women examined and anthropometrically measured at age 17 years between January 1967 and December 2011. Data on pre-malignant disease and invasive cervical tumors were obtained from the national cancer registry by linkage. We excluded non-Jewish minorities (a total of 25 472 women) and orthodox/ultraorthodox Jewish women since these populations are not required by law to serve in the military, as well as women with a pre-examination diagnosis of cancer. Cox proportional hazards regression models were applied per each lesion type, adjusted for origin, measured body mass index, height, education, dwelling type, birth year, and age at examination.

Results In total, 5094 and 859 incident pre-malignant cervical disease and cervical cancer cases, respectively, were diagnosed during a median follow-up of 17.6 years. Risk for both lesions was origin-dependent, with higher incidence in women of North-African origin (HR (pre-malignant cervical disease) 1.22, 95% CI 1.04 to 1.42; HR (cervical cancer) 1.87, 95% CI 1.30 to 2.69) compared with European origin. Height, lower education, and later birth year were associated with higher pre-malignant cervical disease and cervical cancer risk also. Adolescent overweight (HR 0.81, 95% CI 0.74 to 0.90) and obesity (HR 0.56, 95% CI 0.43 to 0.71) status were associated with reduced pre-malignant cervical disease but not cervical cancer incidence, as did urban (vs rural) residence.

Discussion Ethnic background, tall stature, and education were associated with pre-malignant cervical disease and cervical cancer incidence, while adolescent overweight and obesity were inversely associated with only pre-malignant cervical disease. Despite free screening and HPV vaccines, these findings suggest that there is still a need for appropriate safe sex and screening education in adolescence.

  • cervical cancer
  • cervix uteri

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  • Contributors LKB and JDK formatted the study question, planned the study analyses, and interpreted the results. LKB, HL, and JDK carried out the dataset linkage. ED did the quality assurance of the linkages and carried out all statistical analyses. LKB wrote the manuscript. GT, HL, AS, VKM, ED, and JDK critically read the manuscript and reviewedi it.

  • Funding This work was supported by research grants from the Israel Cancer Research Fund (ICRF), and from the Environment and Health Fund (Israel), Award No. RGA 1002, both to J D Kark.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the Israel Defense Forces Medical Corps Institutional Review Board, which waived the requirement for individual informed consent based on strict maintenance of participants' anonymity.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. For reasons of security, no data are available to the general public, and all data analyses were done in a secure research room by a designated person.