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Background A diverse and abundant gut microbiome can improve cancer patients’ treatment response; however, the effect of pelvic chemoradiotherapy (CRT) on gut diversity and composition is unclear. The purpose of this prospective study was to identify changes in the diversity and composition of the gut microbiome during and after pelvic CRT. Materials and methods Rectal swabs from 58 women with cervical, vaginal, or vulvar cancer from two institutions were prospectively analyzed before CRT (baseline), during CRT (weeks 1, 3, and 5), and at first follow-up (week 12) using 16Sv4 rRNA gene sequencing of the V4 hypervariable region of the bacterial 16S rRNA marker gene. 42 of these patients received antibiotics during the study period. Observed operational taxonomic units (OTUs; representative of richness) and Shannon, Simpson, Inverse Simpson, and Fisher diversity indices were used to characterize alpha (within-sample) diversity. Changes over time were assessed using a paired t-test, repeated measures ANOVA, and linear mixed modeling. Compositional changes in specific bacteria over time were evaluated using linear discriminant analysis effect size. Results Gut microbiome richness and diversity levels continually decreased throughout CRT (mean Shannon diversity index, 2.52 vs. 2.91; all P <0.01), but were at or near baseline levels in 60% of patients by week 12. Patients with higher gut diversity at baseline had the steepest decline in gut microbiome diversity. Gut microbiome composition was significantly altered during CRT, with increases in Proteobacteria and decreases in Clostridiales, but adapted after CRT, with increases in Bacteroides species. Conclusion After CRT, the diversity of the gut microbiomes in this population tended to return to baseline levels by the 12 week follow-up period, but structure and composition remained significantly altered. These changes should be considered when designing studies to analyze the gut microbiome in patients who receive pelvic CRT for gynecologic cancers.

Author Contributions: Drs Kouzy and Ludmir had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Kouzy and Abi Jaoude contributed equally as first authors. Drs Taniguchi and Ludmir contributed equally as senior authors.

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Objectives: HPV infection is associated with the development of cervical and oropharyngeal cancer. HPV vaccination prevents cervical cancer, but is still not part of Lebanon's routine vaccination schedule. As such, understanding physicians' practice towards HPV vaccination is essential. Material and Methods: We conducted a cross-sectional study in Greater Beirut, Lebanon to assess the barriers, attitudes and clinical approach of Lebanese physicians towards HPV vaccination. We also aimed to analyze the factors associated with physicians' barriers to HPV vaccination. Results: In total, 228 physicians completed the survey. Our results show that physicians and parents consider the cost of HPV vaccination to be a main barrier (58.9% and 80.7% respectively). Also, parents tend to have concerns about vaccine safety (78.1%), efficacy (68.6%), and lack education concerning HPV infection (81.8%). Furthermore, female physicians tend to have fewer barriers when compared to male physicians (aOR = 0.39; p-value = 0.007). Additionally, physicians who completed residency programs in the USA also showed fewer barriers when compared to physicians who completed Lebanese residency programs (aOR = 0.24; p-value = 0.040). Finally, physicians with higher knowledge score have fewer barriers when compared to those with lower knowledge scores (aOR = 0.42; p-value = 0.018). Conclusions: Physician gender, residency program and level of knowledge play a role in HPV vaccine barriers and recommendation in Lebanon. Future improvements in cost and awareness about HPV might improve vaccination rates. Creating uniform practices towards HPV vaccine is warranted to improve patient care.