24 25
type 18, and p53. The objective of this study is to know the role of p53 in carcinogenesis of cervical cancer with
HPV types 16 and 18 infections. The speciic objectives were: 1.
To know the risk of cervical cancer in case with HPV types 16 and 18 infections compare to the case without HPV infection.
2. To know the risk p53 expression in the case with HPV types 16 and 18 infections were higher
than the case without HPV infection. 3. To know the risk of cervical cancer in the case with p53 expression higher than that case with
out p53 expression. The results of this study may be used for vaccine selection and to elucidate the carcinogenesis
mechanism. Furthermore, it can be used for early diagnosis, gene therapy, prognostic of cervical cancer on biology molecular technique.
2. The Concept Design and Research Hypothesis The Concept Design
The caused of cervical cancer was multifactor. The HPV infection, especially HPV types 16 and 18, was the major risk and the age, parity, early sexual activity, and social economic status were
the minor risks. In cellular, HPV expressed the E1 and E2 proteins which afiliated to E4 and E5. Meanwhile, delayed type of hypersensitivity to E1 and E2 which it makes the low expression of
E1 and E2. And viral was formed continually by L2 until the viral load 50,000 critically [21,22]. The two conditions push down the integration between viral DNA to host DNA. It caused the over
expression of E6 and E7 which its form the E6-p53 and E7-pRB complexes. Its make the degradation of the function of both tumor suppressor proteins. The forming of p53-E7 complex caused the
E2F transcription factor got free and worked without any controlled by pRB. Beside it, pRB trans
activated c-myc [23,24] and c-ras [25] to keep the abnormal gene coniguration. When the impaired of immune response, oncogene, tumor suppressor genes, and repair genes were uncoordinated so
the process improved and progressive to the cervical cancer changes.
The Research Hypothesis 1.
The risk of cervical cancer in the case with HPV types 16 and 18 infections was higher compare with the case without HPV infection.
2. The risk of p53 expression in HPV types 16 and 18 infections were higher than the case without
HPV infection. 3. The risk of cervical cancer in the case with p53 expression higher the the case without p53
expression.
Methods
The research design is a case control study. The study is performed at several departments which are Obstetrics and Gynecology Medical Faculty Udayana University Sanglah Hospital
Denpasar, Pathology of Medical Faculty Udayana University Denpasar, and Biomedical Research Unit of General Hospital Mataram Lombok conducted during November 2003 until December 2004.
Population was the new cervical lesion patients and untreated yet whose examined in Oncology Clinic Sanglah Hospital and concern to the study. Sample was the cervical cancer as a cases and
the non cervical cancer as a controls. Sample size was 30 cases and 30 controls determined by properly role. The data was collected from every department and performed some tests which
available in SPSS for windows 10,0 versions. Furthermore, K-S test for normality, Levene T test for homogeneity and equality, logistic regression to looked for Odds ratio for the risk of cervical cancer
in HPV types 16 and 18 infections, the risk of p53 expression in HPV types 16 and 18 infections, and the risk of cervical cancer in p53 positives.
The Variables and Deinition of Variable The dependent variable was the cervical cancer, the intermediate variables were p53 and pRB,
and independent variables were HPV types 16 and 18. Deinition of Variables :
1. The cervical lesion is the pathology of the cervix by inspection which are leukoplakia, erosion, ulceration, infection, and papilloma of the uterine cervix WHO,1993.
2. Cervical cancer is the the cancer of uterine cervix which diagnosed by clinical and histopathological examination FIGO, 1999.
3. HPV types 16 and 18 were viral DNA positive by PCR using GP MY-6 PCR core System
Promega, USA with the speciic primer of HPV type 16 and HPV type18. 4. The age was the nominal of year which noted at identity card or by interview.
5. The parity was the amount of viable baby that she has given birth by interview. 6.
The early sexual activity was the age when the irst sexual intercourse made or the age when the irst marriage by interview.
7. The social economic status was the ability of the family to earn money by interview or available at the family card in KS criteria BKKBN, 1999.
8. Protein 53 and pRB were the protein positive in immunochemical technique for peroxides method used the p53 primer Lab Vision UK RB-9006-P1. Cut of point was 25 when the
yellow or brawny-yellow nuclear stained.
The patients with cervical lesions, married, and new cases who admitted at Oncology Gynecology
Clinic Sanglah Hospital Denpasar informed this study. After understood the objective, advantage and disadvantage, complication and usefulness of the research and concern to the study, they put
the sign at informed consent form. The specimen carried out from cervical lesion by guidance biopsy and divided in two parts. One part for histopathological examination which performed
at Department of Pathology Medical Faculty Udayana University Denpasar. And other part for
PCR used speciic primers of DNA HPV and the p53 detected by immunohistochemical peroxides anti peroxides method which performed at Biomedical Research Unit General Hospital Mataram
Lombok.
Result and Discussion
The total number of samples was 100 consisted of two groups, 50 for the case of cervical cancer patients and another 50 for the control of non-cervical cancer patients. The incidence of cervical
cancer in Indonesia was 10-20 100,000 women WHO, 1993 and 1: 100,000 populations [3,18]. In Bali province with 3,5 millions people the its incidence was 150-200 per year which clinically
proven by annual data of Obgyn Sanglah Hospital during the last ten years [26,27].
3. The Prevalence of the Age, Parity, Early Sexual Activity, and Social economic Status of Cervical Cancer.
By the aim to increase the internal validity, some variables were controlled by design Table 1.
26 27
Table 1. The Prevalence of the Age, Parity, Early Sexual Activity, and Social Economic Status in Cases and Controls
Risk Factors Cases N=50
Controls N=50 p
Mean SD
Mean SD
Age year 44,22
7,95 39,44
7,27 0,39
Parity 2,92
0,92 2,62
1,26 0,08
Sexual activity 20,52
2,87 20,72
2,94 0,89
Soc-Economic status 2,28
0,67 2,14
0,64 0,06
There were not a signiicant different for those variables p 0,05. So the age, parity, early sexual activity, and social economic status in cases and controls were homogeny.
The average age was 45 ± 8 year, the youngest was 29 and the oldest was 60 years. The wide
variety of age which was recommended by other studies, even there are a case of an 18 years old with cervical cancer stadium III found in Sanglah Hospital Denpasar. Although the trend of the age
decreased in the three last decades but the interval 35-50 years of age was consistent [7,27]. It may be related to the trend of HPV infection by the age and immunity status for speciic age [28,29].
The HPV infection was high in the age of 25, consistent in 25-35 years of age and increased in the age above 35 years old [30]. The L-SIL was most prevalence by year 25-35 [31] and H-SIL by year
over 35 [32,33]. The average parity was 3, the lowest was nuliparous and the higher was 6. That was wide variety of parity in cervical cancer and a similar reported by some studies [26,27,34].
The parity relected of more sexual activity and early sexual activity than labor hazards [30,35]. In addition, the producing of estrogen and progesterone were easy to infect and stabilize the HPV
oncoprotein [36,37]. The average of sexual activity was in the age 21 ± 3 years, the youngest was 15
and oldest was 29 years old. So it looks like the high risk for cervical cancer too. These phenomena related to antigenic of histon in semen [21]
and local immune response to the infection [36]. The middle and lowest of social economic status were found in this study that related to family nutrients
[40] and immune status [41,42]. It was not only lack of quantity but also the quality of micronutrient as zinc, folic acid, cuprum etc [3,30]. Meanwhile for Bali Province, the proile of health showed that
the 10,0 low birth weight, 21,0 lack of chronic calories, the prevalence of struma was 21.5 and nutrient anemia was 63.5 [40].
Based on it can be assumed that almost of the cervical cancer patient were high risk group, especially the lack of immune status.
4. The Prevalence of HPV, HPV Types 16 and 18, and p53 in Cases and Controls.
