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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003ECervical cancer remains a major public health problem worldwide. Current data show that worldwide, there are \u0026gt;500,000 new cases of cervical cancer and \u0026gt;275,000 deaths annually. As many as 85% of the new cases and deaths are occurring in developing countries, where it is the first- or second-leading cause of cancer and related deaths among women [Siegel R et al. \u003Cem\u003ECA Cancer J Clin\u003C\/em\u003E 2013; Globocan 2012]. This article reviews screening and vaccination approaches for cervical cancer prevention.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EVaccinations\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EReproductive Cancers\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ESexually Transmitted Diseases\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EVaccinations\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EReproductive Cancers\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ESexually Transmitted Diseases\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EReproductive Cancers\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EObstetrics \u0026amp; Gynecology\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003ECervical cancer remains a major public health problem worldwide, stated Michael Maxwell Frumovitz, MD, MD Anderson Cancer Center, Houston, Texas, USA, who reviewed screening and vaccination approaches for its prevention.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003ECurrent data show that worldwide, there are \u0026gt;500,000 new cases of cervical cancer and \u0026gt;275,000 deaths annually. As many as 85% of the new cases and deaths are occurring in developing countries, where it is the first- or second-leading cause of cancer and related deaths among women [Siegel R et al. \u003Cem\u003ECA Cancer J Clin\u003C\/em\u003E 2013; Globocan 2012]. Some 3.4 million women-years of life are lost annually to cervical cancer. In the United States, public health efforts have successfully reduced cervical cancer by about 70% with Papanicolaou (Pap) test screening over the past 40 years, and it is now the 14th most frequent cancer among women, with approximately 12,000 new cases and 4,000 deaths annually.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPREVENTION OPPORTUNITIES\u003C\/h2\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EThe natural history of cervical cancer provides multiple opportunities for prevention (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). Cervical infection by human papillomavirus (HPV) is the genesis of cervical cancer, causing a local infection on the cervix. Most immunocompetent young women (about 90%) will clear an HPV infection in 2 years [Ho et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 1998]. A persistent infection leads to cervical dysplasia, which will regress without intervention in about 70% of cases of low-grade dysplasia and in some cases of high-grade dysplasia. A small number of lesions will progress from low grade to high grade and eventually to cervical cancer, a process that generally takes 10 to 15 years. Dysplasia can be treated with surgical resection, laser ablation, and cryotherapy, among other accepted techniques, while emerging technologies and immunotherapy are being explored.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/7\/6\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Opportunities to Intervene to Prevent Cervical Cancer\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-110103692\u0022 data-figure-caption=\u0022Opportunities to Intervene to Prevent Cervical Cancer\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/7\/6\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/7\/6\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/7\/6\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15967\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003EOpportunities to Intervene to Prevent Cervical Cancer\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from Michael Maxwell Frumovitz, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EVACCINATION TO REDUCE CERVICAL CANCER\u003C\/h2\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EHPV is the most common sexually transmitted disease, and the initial infection usually occurs during adolescence, within 18 months of sexual debut. Notably, 80% of women will have HPV infections during their lifetimes, of whom \u0026lt;5% will have significant preinvasive disease and \u0026lt;1% will have invasive cervical cancer [Centers for Disease Control and Prevention 2004; Baseman JG, Koutsky LA. \u003Cem\u003EJ Clin Virol\u003C\/em\u003E 2005].\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EThe 2 approved vaccines have an efficacy of 93% to 100% against high-risk HPV types in adolescent girls between 16 and 18 years of age [Garland SM et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2007; The FUTURE II Study Group. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2007; Lehtinen M. \u003Cem\u003ELancet Oncol\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003E\n            \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E summarizes the recommendations for vaccination of 4 key medical societies.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15969\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15969\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15969\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003ERecommendations for HPV Vaccination\u003Csup\u003E*\u003C\/sup\u003E\n               \u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EVaccination of adolescent boys (with recombinant HPV quadrivalent [types 6,11,16, and 18] vaccine) is also recommended to prevent genital warts and potentially to prevent other HPV-associated cancers (anal, penile, or oropharyngeal). HPV is estimated to be the cause of about 75% of oropharyngeal cancers. Furthermore, vaccination of boys is thought to decrease HPV transmission to female partners and to provide greater protection of the public by decreasing infection in those who do not receive vaccination.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EThe impact of vaccination was estimated using mathematical models of the data from the Papilloma Trial Against Cancer in Young Adults trial [Van Kriekinge G et al. \u003Cem\u003EVaccine\u003C\/em\u003E 2014]. Vaccination of 70% of adolescent girls worldwide would lead to a 50% reduction in cancers associated with HPV-16 and HPV-18, a reduction of 345,000 new cases of overall cervical cancer, and the prevention of 179,000 deaths due to cervical cancer [Van Kriekinge G et al. \u003Cem\u003EVaccine\u003C\/em\u003E 2014].\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EA mandatory vaccination program of schoolgirls in Australia with a quadrivalent vaccine provides real-world data on the benefit of vaccination and shows that a strong nationwide vaccination program reduces the morbidity and eventually the mortality associated with cervical cancer, said Dr. Frumovitz. A 90% reduction in reports to national health authorities was observed within 2 years of the initiation of the mandatory HPV vaccination program in Australia [Fairley CK et al. \u003Cem\u003ESex Transm Infect\u003C\/em\u003E 2009]. Another study showed a 40% reduction in high-grade dysplasia in women younger than 18 years of age within 3 years of the initiation of the mandatory Australian program [Brotherton JM et al. \u003Cem\u003ELancet\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003ERates of HPV vaccination range from \u0026gt;70% in Australia, Canada, the United Kingdom, and Panama to only 33% of girls and 7% of boys completing the 3-dose series in the United States \u003Cem\u003E[Morbid Mortal Wkly Rep\u003C\/em\u003E 2013].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ERECOMMENDATIONS FOR CERVICAL CANCER SCREENING\u003C\/h2\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EScreening for cervical cancer is highly effective, stated Dr. Frumovitz, as shown by the 70% reduction in cervical cancer at 7 years after a national screening program began in England in 1988 [Quinn et al. \u003Cem\u003EBMJ\u003C\/em\u003E 1999]. Screening is necessary because of the low uptake of HPV vaccination and because it does not cover all the high-risk subtypes.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EThree governing bodies updated their recommendations for cervical cancer screening in 2012. These were the joint American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology guidelines [Saslow D et al. \u003Cem\u003EJ Low Genit Tract Dis\u003C\/em\u003E 2012]; the American Congress of Obstetricians and Gynecologists [Committee on Practice Bulletins\u2014Gynecology. \u003Cem\u003EObstet Gynecol\u003C\/em\u003E 2012]; and the US Preventive Services Task Force [Moyer VA. \u003Cem\u003EAnn Intern Med\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EFor women at average risk, screening should begin at 21 years of age and continue at 3-year intervals through age 29 years. For women ages 30 to 65 years, the guidelines are in agreement that screening should take place every 5 years with both cervical cytology and HPV testing and that cervical cytology alone every 3 years is acceptable. For women older than 65 years who had previous abnormal Pap smear results, screening should continue until there are 15 to 20 years of normal Pap smear results, even past the age of 65 years. In the future, with more data on screening efficacy, it may be that cervical cytology will be used to determine which HPV-positive women should be followed or undergo colposcopy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EThe American Society for Colposcopy and Cervical Pathology\u0027s management algorithm for screening women \u003Csup\u003E3\u003C\/sup\u003E30 years of age who are HPV positive and have normal Pap smear results is shown in \u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E [Massad LS et al. \u003Cem\u003EObstet Gynecol\u003C\/em\u003E 2013; Saslow D et al. \u003Cem\u003EJ Low Genit Tract Dis\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/7\/6\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022American Society for Colposcopy and Cervical Pathology Screening Algorithm\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-110103692\u0022 data-figure-caption=\u0022American Society for Colposcopy and Cervical Pathology Screening Algorithm\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/7\/6\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/7\/6\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/7\/6\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15968\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-20\u0022 class=\u0022first-child\u0022\u003EAmerican Society for Colposcopy and Cervical Pathology Screening Algorithm\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EASC=atypical squamous cells; ASCCP=American Society for Colposcopy and Cervical Pathology; DNA=deoxyribonucleic acid; HPV=human papillomavirus.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EReproduced with permission from Lippincott, Williams \u0026amp; Wilkins from Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. \u003Cem\u003EJ Low Genit Tract Dis\u003C\/em\u003E 2012;16(3):175\u2013204.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EThe use of Pap smears for screening is limited by their low sensitivity and specificity, resulting in high rates of false-negative and false-positive results, respectively, stated Dr. Frumovitz. This has led to screening strategies that now start with HPV testing. One such strategy recommends routine screening for HPV-negative patients, while HPV-positive patients should undergo reflex cytology with or without HPV genotyping to determine the need for further screening or colposcopy [Wright TC Ir. \u003Cem\u003EClin Ob Gyn\u003C\/em\u003E 2007].\u003C\/p\u003E\n         \u003Cp id=\u0022p-22\u0022\u003EHPV testing is more sensitive and reproducible than Pap testing [Mayrand MH et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2007], is more upstream in the carcinogenic process, can be automated and centralized, and is more cost-effective, stated Dr. Frumovitz. Based on data from the Addressing the Need for Advanced HPV Diagnostics trial [Cox IT et al. \u003Cem\u003EAm J Obstet Gynecol\u003C\/em\u003E 2012; Castle PE et al. \u003Cem\u003ELancet\u003C\/em\u003E Oncol 2011], the US Food and Drug Administration recently approved a new screening tool (cobas HPV Test) for cervical cancer screening said Dr. Frumovitz.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/7\/6.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzp8y2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzp8y2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzp8y2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}