Silvia de Sanjosé

IDIBELL Bellvitge Biomedical Research Institute, Barcino, Catalonia, Spain

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Publications (364)2064.08 Total impact

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    ABSTRACT: Background Country-level HPV genotyping data may be sought by decision-makers to gauge the genotype-specific burden of HPV-related diseases in their jurisdiction and assess the potential impact of HPV vaccines. We investigated, by country, the availability of published literature on HPV genotypes in cervical, vaginal and vulvar cancers and intraepithelial neoplasms (CINs, VaINs and VINs) and on prevalence and incidence of genital HPV infections among women without clinically manifest disease. Findings Primary sources of publications were the PubMed/Medline and EMBASE databases. Original studies or meta-analyses published from 2000, covering genotypes 16 and 18 and at least one of genotypes 31/33/45/52/58, were included. Key exclusion criteria were language not English, cervical lesions not histologically confirmed (cytology only), special populations (e.g., immunocompromised) and, for cervical studies, small population (<50). A total of 727 studies reporting HPV genotype-specific data were identified: 366 for cervical cancers and CINs, 43 for vulvar or vaginal cancers and VINs/VaINs, and 395 and 21 for infection prevalence and incidence, respectively, in general female population samples. A large proportion of studies originated from a small set of countries. Cervical cancer/CIN typing data was scarce for several regions with the highest cervical cancer burden, including Eastern, Middle and Western Africa, Central America, South-East Asia, South Asia, and Eastern Europe. Data for vulvar/vaginal disease was limited outside of Europe and North America. Conclusions Although a large body of published HPV genotype-specific data is currently available, data gaps exist for genotype-specific infection incidence and several world regions with the highest cervical cancer burden. Electronic supplementary material The online version of this article (doi:10.1186/s13027-015-0008-y) contains supplementary material, which is available to authorized users.
    Infectious Agents and Cancer 12/2015; 10(1). DOI:10.1186/s13027-015-0008-y · 2.36 Impact Factor
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    ABSTRACT: The colonic opportunist Streptococcus gallolyticus subspecies gallolyticus (SGG) is potentially associated with colorectal cancer (CRC). Large-scale seroepidemiological data for SGG antibodies and their possible association with CRC is currently missing. Associations between CRC and antibody responses to SGG were examined in 576 CRC cases and 576 controls matched by sex, age and province from a population-based multicase-control project (MCC-Spain). MCC-Spain was conducted between 2008 and 2013 in 12 Spanish provinces. Antibody responses to recombinant affinity-purified SGG pilus proteins Gallo1569, 2039, 2178 and 2179 were analysed by multiplex serology. Polyomavirus (PyV) JC VP1 and PyV 6 VP1 proteins served as disease-specificity controls. In the control population, antibody responses to pilus proteins were mostly weak. Antibody responses to individual pilus proteins Gallo2039 (OR: 1.58, 95% CI: 1.09-2.28), Gallo2178 (OR: 1.58, 95% CI: 1.09-2.30) and Gallo2179 (OR: 1.45, 95% CI: 1.00-2.11) were significantly associated with CRC risk. The association was stronger for positivity to 2 or more pilus proteins of Gallo1569, Gallo2178 and Gallo2179 (OR:1.93, 95% CI: 1.04-3.56) and for double-positivity to Gallo2178 and Gallo2179 (OR: 3.54, 95% CI: 1.49-8.44). The association between SGG infection and CRC risk was stronger among individuals younger than 65 years. For the first time we demonstrated a statistically significant association of exposure to SGG antigens and CRC in a large seroepidemiological study. These results should stimulate further studies on the role of SGG in CRC pathogenesis. This article is protected by copyright. All rights reserved.
    International Journal of Cancer 11/2015; DOI:10.1002/ijc.29914 · 5.09 Impact Factor

  • Cancer Epidemiology Biomarkers & Prevention 10/2015; DOI:10.1158/1055-9965.EPI-15-0953 · 4.13 Impact Factor
  • Helen Kelly · Philippe Mayaud · Silvia de Sanjose ·

    09/2015; DOI:10.1007/s13669-015-0132-0

  • Cancer Epidemiology Biomarkers & Prevention 09/2015; DOI:10.1158/1055-9965.EPI-15-0534 · 4.13 Impact Factor
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    ABSTRACT: Background Anal warts are common in HIV+ individuals and among men who have sex with men (MSM). Condylomata, generally attributable to infection by low-risk human papillomaviruses (HPVs), are considered benign low-grade squamous intraepithelial lesions (LSILs). However, anal condylomata have occasionally been linked to high-grade SIL (HSIL) and to oncogenic, high-risk HPVs. Objectives Here we describe the histopathology of anal SILs and of the associated HPV type and variant distribution in HIV+ and HIV- patients. Methods A total of 480 baseline and 167 recurrent FFPE anogenital wart (AGW) samples were collected from 302 patients. Baseline of 179 perianal and 145 anal warts were analyzed among 243 patients (56 heterosexual women, 61 heterosexual men and 126 MSM, including 41 HIV+ MSM). Lesion histopathology, including p16/p53 biomarkers, and associated HPV types and variants were assessed. Results In total 98.6% of AGWs showed the presence of HPV DNA. MSM showed a higher proportion of perianal/anal condylomata as HSILs compared to heterosexuals. HIV+ MSM (compared to HIV-) presented 4-fold increased prevalence of perianal LSILs containing only oncogenic HPVs, while more than 64% of anal HSILs among MSM were only associated with low-risk HPVs. Histopathology revealed that 59.3% of the HSILs were flat lesions and 93.8% of these cases were p16 positive and associated with oncogenic HPVs. In contrast, 70.0% of condylomatous HSILs were exclusively associated with low-risk HPV. Recurrent AGWs with baseline HPV type detected were associated with the same HPV variant. Conclusion Perianal LSILs were commonly associated with oncogenic HPV types in HIV+ MSM, while anal HSILs associated only with low-risk HPV types were common in both MSM groups. Taken together, clinical diagnosis of condylomata in patients requiring surgical anal treatment cannot be assumed to be only benign low-risk HPV associated low-grade lesions, particularly among MSM and HIV+ patients.
    29th European conference on sexually transmitted infections, Sitges, Barcelona; 09/2015
  • Leonidas Georgalis · Silvia de Sanjosé · Mikel Esnaola · F Xavier Bosch · Mireia Diaz ·
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    ABSTRACT: Human papillomavirus (HPV) vaccination within a nonorganized setting creates a poor cost-effectiveness scenario. However, framed within an organized screening including primary HPV DNA testing with lengthening intervals may provide the best health value for invested money. To compare the effectiveness and cost-effectiveness of different cervical cancer (CC) prevention strategies, including current status and new proposed screening practices, to inform health decision-makers in Spain, a Markov model was developed to simulate the natural history of HPV and CC. Outcomes included cases averted, life expectancy, reduction in the lifetime risk of CC, life years saved, quality-adjusted life years (QALYs), net health benefits, lifetime costs, and incremental cost-effectiveness ratios. The willingness-to-pay threshold is defined at 20 000&OV0556;/QALY. Both costs and health outcomes were discounted at an annual rate of 3%. A strategy of 5-year organized HPV testing has similar effectiveness, but higher efficiency than 3-year cytology. Screening alone and vaccination combined with cytology are dominated by vaccination followed by 5-year HPV testing with cytology triage (12 214&OV0556;/QALY). The optimal age for both ending screening and switching age from cytology to HPV testing in older women is 5 years later for unvaccinated than for vaccinated women. Net health benefits decrease faster with diminishing vaccination coverage than screening coverage. Primary HPV DNA testing is more effective and cost-effective than current cytological screening. Vaccination uptake improvements and a gradual change toward an organized screening practice are critical components for achieving higher effectiveness and efficiency in the prevention of CC in Spain.
    European journal of cancer prevention: the official journal of the European Cancer Prevention Organisation (ECP) 09/2015; DOI:10.1097/CEJ.0000000000000202 · 3.03 Impact Factor

  • Cancer Cytopathology 09/2015; DOI:10.1002/cncy.21622 · 3.35 Impact Factor
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    ABSTRACT: Various occupations have been associated with an elevated NHL risk but results have been inconsistent across studies. To investigate occupational risk of non-Hodgkin lymphoma (NHL) and four common NHL subtypes with particular focus on occupations of a priori interest. We conducted a pooled analysis of 10,046 cases and 12,025 controls from 10 NHL studies participating in the InterLymph Consortium. We harmonized the occupational coding using the 1968 International Standard Classification of Occupations (ISCO) and grouped occupations previously associated with NHL into 25 a priori groups. Odds ratios (OR), adjusted for center, age and sex were determined for NHL overall and the subtypes diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and peripheral T-cell lymphoma (PTCL). We confirmed previously reported positive associations between NHL and farming occupations (field crop/vegetable farm workers OR = 1.26; 95% confidence interval (CI): 1.05, 1.51; general farm workers OR = 1.19, 95% CI: 1.03, 1.37), and with specific occupations as women's hairdressers (OR = 1.34; 95% CI: 1.02, 1.74), charworkers/cleaners (OR = 1.17; 95% CI: 1.01, 1.36), spray-painters (OR = 2.07; 95% CI: 1.30, 3.29), electrical wiremen (OR = 1.24; 95% CI: 1.00, 1.54), and carpenters (OR = 1.42; 95% CI: 1.04, 1.93). We observed subtype specific associations for DLBCL and CLL/SLL in women's hairdressers and for DLBCL and PTCL in textile workers. Our pooled analysis of 10 international studies adds to evidence suggesting that farming, hairdressing, and textile industry-related exposures may contribute to NHL risk. Associations with women's hairdresser and textile occupations may be specific for certain NHL subtypes.
    Environmental Health Perspectives 09/2015; DOI:10.1289/ehp.1409294 · 7.98 Impact Factor
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    ABSTRACT: Human papillomavirus (HPV)-related screening technologies and HPV vaccination offer enormous potential for cancer prevention, notably prevention of cervical cancer. The effectiveness of these approaches is, however, suboptimal owing to limited implementation of screening programmes and restricted indications for HPV vaccination. Trials of HPV vaccination in women aged up to 55 years have shown almost 90% protection from cervical precancer caused by HPV16/18 among HPV16/18-DNA-negative women. We propose extending routine vaccination programmes to women of up to 30 years of age (and to the 45-50-year age groups in some settings), paired with at least one HPV-screening test at age 30 years or older. Expanding the indications for HPV vaccination and much greater use of HPV testing in screening programmes has the potential to accelerate the decline in cervical cancer incidence. Such a combined protocol would represent an attractive approach for many health-care systems, in particular, countries in Central and Eastern Europe, Latin America, Asia, and some more-developed parts of Africa. The role of vaccination in women aged >30 years and the optimal number of HPV-screening tests required in vaccinated women remain important research issues. Cost-effectiveness models will help determine the optimal combination of HPV vaccination and screening in public health programmes, and to estimate the effects of such approaches in different populations.
    Nature Reviews Clinical Oncology 09/2015; DOI:10.1038/nrclinonc.2015.146 · 14.18 Impact Factor
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    ABSTRACT: Objective. Audit of women with invasive cervical cancer (CC) is critical for quality control within screening activities. We analysed the screening history in the 10 years preceding the study entry in women with and without CC during 2000-2011. Methods. 323 women with CC from six pathology departments in Catalonia (Spain) and 23,782 women with negative cytology were compared. Age, previous history of cytologies, and histological type and FIGO stage were collected from the pathology registries. Logistic regression analysis was used to estimate odds ratios (OR) and 95% confidence intervals (CI95%). Results. History of cytology was registered in 26.2% of CC cases and in 78% of the control women () and its frequency decreased with increasing age. Compared to women with squamous cell carcinoma, adenocarcinoma cases were significantly more likely to have a cytology within the 3-year interval preceding cancer diagnosis ( CI 95%: 1.2-5.6) and to have normal cytology results in previous screenings ( CI 95%: 1.2-4.5). FIGO II-IV cases were more common among older women (older than 60 years). Conclusions. Absence of prior screening history was extremely common among CC cases compared to controls. Organized actions to reduce underscreened women and use of highly sensitive HPV-based tests could be important to reduce CC burden.
    07/2015; 2015:1-9. DOI:10.1155/2015/605375
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    ABSTRACT: This study aims to describe time trends in and patterns of use of hormonal contraception and postmenopausal hormone therapy and to identify factors associated with their use among Spanish women. We performed a cross-sectional analysis using data from 1,954 population controls (aged 24-85 y) in 12 provinces of Spain who were enrolled in the Multi Case-Control Spain study (2007-2013). Data were collected from a questionnaire conducted face-to-face by trained personnel. We collected information on sociodemographic factors, lifestyle, sleep patterns, reproductive history, and occupational history. Overall, 48.5% of Spanish women reported ever use of hormonal contraception, and 9.8% of women in the postmenopausal group reported use of postmenopausal hormone therapy. Younger cohorts used hormonal contraception for a longer period, whereas postmenopausal hormone therapy use dramatically dropped in the 2000s. Women with higher education levels (including education of partners) and smoking history were the most probable users of hormonal contraception, whereas inverse associations were observed among housewives, obese women, and nulliparous women. Postmenopausal hormone therapy use was associated with a surgical or therapeutic cause of menopause and with occupational history of rotating shifts. In this Spanish population, several demographic, lifestyle, occupational, and reproductive factors are associated with use of hormonal compounds. Characterizing hormonal users and monitoring trends in the use of these hormonal compounds are essential from a public health perspective.
    Menopause (New York, N.Y.) 06/2015; 72. DOI:10.1097/GME.0000000000000487 · 3.36 Impact Factor
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    ABSTRACT: Human papillomavirus (HPV) vaccines can potentially control cervical cancer and help to reduce other HPV-related cancers. We aimed to estimate the relative contribution (RC) of the nine types (HPVs 16/18/31/33/45/52/58/6/11) included in the recently approved 9-valent HPV vaccine in female anogenital cancers and precancerous lesions (cervix, vulva, vagina and anus). Estimations were based on an international study designed and coordinated at the Catalan Institute of Oncology (Barcelona-Spain), including information on 10,575 invasive cervical cancer (ICC), 1709 vulvar, 408 vaginal and 329 female anal cancer cases and 587 Vulvar Intraepitelial Neoplasia grade 2/3 (VIN2/3), 189 Vaginal Intraepitelial Neoplasia grade 2/3 (VaIN2/3) and 29 Anal Intraepitelial Neoplasia grade 2/3 (AIN2/3) lesions. Consecutive histologically confirmed paraffin-embedded cases were obtained from hospital pathology archives from 48 countries worldwide. HPV DNA-detection and typing was performed by SPF10-DEIA-LiPA25 system and RC was expressed as the proportion of type-specific cases among HPV positive samples. Multiple infections were added to single infections using a proportional weighting attribution. HPV DNA prevalence was 84.9%, 28.6%, 74.3% and 90.0% for ICC, vulvar, vaginal and anal cancers, respectively, and 86.7%, 95.8% and 100% for VIN2/3, VaIN2/3 and AIN2/3, respectively. RC of the combined nine HPV types was 89.5% (95% confidence interval (CI): 88.8-90.1)-ICC, 87.1% (83.8-89.9)-vulvar, 85.5% (81.0-89.2)-vaginal, 95.9% (93.0-97.9)-female anal cancer, 94.1% (91.7-96.0)-VIN2/3, 78.7% (71.7-84.2)-VaIN2/3 and 86.2% (68.3-96.1)-AIN2/3. HPV16 was the most frequent type in all lesions. Variations in the RC of HPVs 31/33/45/52/58 by cancer site were observed, ranging from 7.8% (5.0-11.4)-female anal cancer to 20.5% (16.1-25.4)-vaginal cancer. The addition of HPVs 31/33/45/52/58 to HPV types included in current vaccines (HPV16/18) could prevent almost 90% of HPV positive female anogenital lesions worldwide. Taking into account that most HPV-related cancers are ICC ones, the 9-valent HPV vaccine could potentially avoid almost 88% of all female anogenital cancers. Copyright © 2015. Published by Elsevier Ltd.
    European journal of cancer (Oxford, England: 1990) 06/2015; 51(13). DOI:10.1016/j.ejca.2015.06.001 · 5.42 Impact Factor
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    ABSTRACT: Very limited information is available regarding the incidence of cancer in sub-Saharan Africa. We analyzed changes in cancer patterns from 1991 to 2008 in Maputo (Mozambique). We calculated the rates of incidence of different cancer sites by sex in the 5-year age-group of the population of Maputo city as well as age-standardized rates (ASRs) and average annual percentage changes (AAPC). Over the 18-year study period a total of 12,674 cases of cancer (56.9% females) were registered with an overall increase in the risk of cancer in both sexes. In males, the most common cancers were those of the prostate, Kaposi sarcoma (KS) and the liver. Prostate cancer showed the most dramatic increase over the whole study period (AAPC +11.3%; 95% CI: 9.7-13.0), with an ASR of 61.7 per 105 in 2003-2008. In females, the most frequent cancers were of the uterine cervix, the breast and KS, with the former increasing along the whole study period (AAPC + 4.7%; 95% CI: 3.4-6) with an ASR of 62.0 per 105 in 2003-2008 as well as breast cancer (AAPC +6.5%; 95%CI: 4.3-8.7). Overall, the risk of cancer rose in both sexes during the study period, particularly among cancers associated with westernization of lifestyles (prostate, breast), combined with increasingly rising incidences or limited changes in cancers associated with infection and poverty (uterine cervix, liver). Moreover, the burden of AIDS-associated cancers has shown a marked increase.
    PLoS ONE 06/2015; 10(6):e0130469. DOI:10.1371/journal.pone.0130469 · 3.23 Impact Factor
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    ABSTRACT: A second generation HPV vaccine has been developed for the prevention of anogenital cancers and precancerous lesions of the cervix, vulva, vagina, anus and of genital warts due to nine HPV types.
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    ABSTRACT: Excess adiposity has been associated with lymphomagenesis, possibly mediated by increased cytokine production causing a chronic inflammatory state. The relationship between obesity, cytokine polymorphisms and selected mature B-cell neoplasms is reported. Data on 4979 cases and 4752 controls from nine American/European studies from the InterLymph consortium (1988-2008) were pooled. For diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL) and chronic lymphocytic leukaemia/small lymphocytic lymphoma (CLL/SLL), joint associations of body mass index (from self-reported height and weight) and 12 polymorphisms in cytokines IL1A (rs1800587), IL1B (rs16944, rs1143627), IL1RN (rs454078), IL2 (rs2069762), IL6 (rs1800795, rs1800797), IL10 (rs1800890, rs1800896), TNF (rs1800629), LTA (rs909253), and CARD15 (rs2066847) were investigated using unconditional logistic regression. BMI-polymorphism interaction effects were estimated using the relative excess risk due to interaction (RERI). Obesity (BMI≥30kg m-2) was associated with DLBCL risk (OR=1.33, 95%CI 1.02-1.73), as was TNF-308GA+AA (OR=1.24, 95%CI 1.07-1.44). Together, being obese and TNF-308GA+AA increased DLBCL risk almost two-fold relative to those of normal weight and TNF-308GG (OR=1.93 95%CI 1.27-2.94), with a RERI of 0.41 (95%CI -0.05,0.84, P(interaction)=0.13). For FL and CLL/SLL, no associations with obesity or TNF-308GA+AA, either singly or jointly, were observed. No evidence of interactions between obesity and the other polymorphisms were detected. Our results suggest that cytokine polymorphisms do not generally interact with BMI to increase lymphoma risk but obesity and TNF-308GA+AA may interact to increase DLBCL risk. Studies using better measures of adiposity are needed to further investigate the interactions between obesity and TNF-308G>A in the pathogenesis of lymphoma. Copyright © 2015, American Association for Cancer Research.
    Cancer Epidemiology Biomarkers & Prevention 05/2015; 24(7). DOI:10.1158/1055-9965.EPI-14-1355 · 4.13 Impact Factor
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    ABSTRACT: Hepatitis C virus (HCV) infection is a significant global health issue because it is widespread and persistent and can cause serious liver diseases. The aim of this study is to estimate HCV prevalence in women from the general population in different geographical areas worldwide and to assess the potential role of sexual behaviour in the virus transmission. Each participating centre recruited a random sample of women from the general population aged from less than 20 to more than 75 years. The study included 8130 women from 8 countries with information on sociodemographic factors, reproductive and sexual behaviour, smoking habit and HPV DNA through individual interviews. A blood sample was also collected to perform serological tests. We estimated the prevalence ratios associated to HCV to evaluate the effect of sexual behaviour in viral transmission. Women were reactive to a minimum of two HCV antigens, including at least one non structural protein were considered as positive (33% of the samples were classified as positive, 40% as negative, and 27% as indeterminate (N=402), that were considered as not positive). The age-adjusted HCV seroprevalence varied significantly by regions (0.3% in Argentina to 21.1% in Nigeria). We found no association between HCV prevalence and age, educational level, smoking habit and any of the available variables for sexual behaviour and reproductive history. This large study showed heterogeneous distribution of HCV seroprevalence in female and provides evidence of the null impact of sexual behaviour in HCV transmission. Copyright © 2015 Elsevier B.V. All rights reserved.
    Journal of clinical virology: the official publication of the Pan American Society for Clinical Virology 05/2015; 68. DOI:10.1016/j.jcv.2015.05.005 · 3.02 Impact Factor
  • Silvia de Sanjosé ·

    ecancermedicalscience 04/2015; 9. DOI:10.3332/ecancer.2015.532 · 1.20 Impact Factor
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    ABSTRACT: Merkel cell polyomavirus (MCPyV) has been suspected to cause chronic lymphocytic leukemia (CLL) but previous data are inconsistent. We measured seroreactivities of 9 polyomaviruses (MCPyV, BKPyV, JCPyV, LPyV, KIPyV, WUPyV, HPyV-6, HPyV-7 and TSPyV) in 359 CLL cases and 370 controls using bead-based multiplex serology technology. We additionally tested two herpesviruses (HSV-1 and CMV). Associations between disease and viral seroreactivities were assessed using logistic regression. All human viruses showed high seroprevalences (69-99%) against structural proteins in controls but significant lower viral seroprevalences in cases (58-94%; OR range=0.21-0.70, p-value<0.05), except for MCPyV (OR=0.79, 95%CI=0.54-1.16). Lower seroreactivity levels were observed among CLL subjects, with significant differences already observed at early stages of diseases, unrelated to treatment status. Seroreactivities against polyomaviruses related oncoproteins were almost null. Our data suggest no association for MCPyV polyomavirus with CLL development and an unlikely association for other polyomaviruses tested.
    Journal of General Virology 04/2015; 96(8). DOI:10.1099/vir.0.000167 · 3.18 Impact Factor
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    Anna R Giuliano · Aimée R Kreimer · Silvia de Sanjose ·

    Journal of the National Cancer Institute 04/2015; 107(6). DOI:10.1093/jnci/djv128 · 12.58 Impact Factor

Publication Stats

20k Citations
2,064.08 Total Impact Points


  • 2009-2015
    • IDIBELL Bellvitge Biomedical Research Institute
      Barcino, Catalonia, Spain
  • 2001-2015
    • Catalan Institute of Oncology
      • • Infections and Cancer Unit
      • • Cancer Epidemiology Research Programme (PREC)
      Badalona, Catalonia, Spain
  • 1996-2015
    • Institut Català d'Oncologia
      Barcino, Catalonia, Spain
  • 2014
    • National Institutes of Health
      • Branch of Radiation Epidemiology
      베서스다, Maryland, United States
    • Mayo Clinic - Rochester
      • Department of Health Science Research
      Рочестер, Minnesota, United States
  • 2008-2014
    • Institut Marqués, Spain, Barcelona
      Barcino, Catalonia, Spain
    • IDIBGI Girona Biomedical Research Institute
      Girona, Catalonia, Spain
    • Lund University
      Lund, Skåne, Sweden
  • 2004-2014
    • National Cancer Institute (USA)
      • Radiation Epidemiology
      베서스다, Maryland, United States
  • 2013
    • University of Barcelona
      Barcino, Catalonia, Spain
    • Barcelona Media
      Barcino, Catalonia, Spain
  • 2012-2013
    • Madrid Salud
      Madrid, Madrid, Spain
    • Vall d’Hebron Institute of Oncology
      Barcino, Catalonia, Spain
  • 2011
    • DDL Diagnostic Laboratory
      Rijswijk, South Holland, Netherlands
    • University of Amsterdam
      Amsterdamo, North Holland, Netherlands
  • 2010
    • University of California, Berkeley
      • School of Public Health
      Berkeley, California, United States
    • Instituto Valenciano de Oncologia
      Valenza, Valencia, Spain
  • 2003
    • VU University Medical Center
      Amsterdamo, North Holland, Netherlands
  • 2000
    • Johns Hopkins Bloomberg School of Public Health
      Baltimore, Maryland, United States
  • 1995
    • Hospital Universitario Virgen del Rocío
      Hispalis, Andalusia, Spain