Dr nisreen anfnan cervical cancer in saudi arabia last version

Cervical cancer in Saudi Arabia

Dr. Nisreen Anfinan

Cervical Cancer: Worldwide Prevalence,

Incidence, and Mortality Estimates

Cervical cancer is the 2nd most common cancer among

women worldwide

Estimated 530,000 new cases

Estimated 274,000 deaths

More than 85% of the global burden occurs in developing

countries .

GLOBOCAN2008

Cervical Cancer in Saudi Arabia

Incidence of cervical cancer is low in Saudi Arabia

Rank number 11 between all cancers in female

Every year, 152 women are diagnosed with cervical cancer and 55 die from the disease. new cervical cancer cases and deaths in 2025 are 309

Account only 2.4 % of all cases

SCR Report 2009

Cancer in Saudi Arabia

SCR Report 2009

Age specific incidence rate for cancer cervix

in SA

SCR Report 2009


In view of the lack of national screening programs, the

actual reason for this low incidence is unknown ??

The society and standards of mores could make Muslim

women less susceptible to HPV infection

Authora Duration Total no Abnormal

PAP smear ASC-US ASC-H LSIL HSIL AGUS

INVASIVE

CANCER

Al-Jaroudi (1) 2008 – 2009 2417

(2.9%)

3

(1.2%)

1

(0.4%)

2

(0.83%)NR

1

(0.4%)NR

Jamal (2) 1984 – 2000 22089368

(1.66%)

88

(0.4%)NR

81

(0.37%)

72

(0.32%)

36

(0.16%)

26

(0.1%)

Altaf (3) 2001 308897

(3.14%)

14

(0.45%)NR

29

(0.93%)

17

(0.55%)

4

(0.13%)

5

(0.16%)

Abdullah L (4) 1998 – 2005 5590261

(4.7%)

103

(1.84%)

6

(0.10%)

5

(0.09%)

31

(0.55%)

30

(0.53%)

2

(0.04%)

Altaf(5) 2000 – 2004 5132241

(4.7%)

124

(2.4%)NR

31

(0.6%)

22

(0.4%)

58

(1.1%)

6

(0.1%)

Bondagi N(6) 2010 – 2011 485 (5.6% _ _ _ _ _ _

Ann Saudi Med 2010, Saudi Med J 2003, Ann Saudi

Med 2001, Ann Saudi Med; 27, Saudi Med J 2006

Authora Duration Total no Abnormal

PAP smear ASC-US ASC-H LSIL HSIL AGUS

INVASIVE

CANCER

Al-Jaroudi (1) 2008 – 2009 2417

(2.9%)

3

(1.2%)

1

(0.4%)

2

(0.83%)NR

1

(0.4%)NR

Jamal (2) 1984 – 2000 22089368

(1.66%)

88

(0.4%)NR

81

(0.37%)

72

(0.32%)

36

(0.16%)

26

(0.1%)

Altaf (3) 2001 308897

(3.14%)

14

(0.45%)NR

29

(0.93%)

17

(0.55%)

4

(0.13%)

5

(0.16%)

Abdullah L (4) 1998 – 2005 5590261

(4.7%)

103

(1.84%)

6

(0.10%)

5

(0.09%)

31

(0.55%)

30

(0.53%)

2

(0.04%)

Altaf(5) 2000 – 2004 5132241

(4.7%)

124

(2.4%)NR

31

(0.6%)

22

(0.4%)

58

(1.1%)

6

(0.1%)

Bondagi N(6) 2010 – 2011 485 (5.6% _ _ _ _ _ _

Ann Saudi Med 2010, Saudi Med J 2003, Ann Saudi

Med 2001, Ann Saudi Med; 27, Saudi Med J 2006

Human Papilloma virus

HPV is a relatively small virus1 containing circular double-stranded DNA within a spherical shell (capsid)1

100 nm

1. Burd EM. Clin Microbiol Rev 2003; 16:1–17.

Africa

22.9

Asia

8.3.%

Central

America

20.5%

North America

13.8%

South

America

14.3%

Europe

6.6 %

The Lancet Infectious Diseases Jul 2007

HPV prevalence in Saudi Arabia

Author No of patients HPV prevalence

Al mummar 2007 120 38 (31.6% )

Gazzaz 2007 100 5 (5% )

Bondoggi 2013 485 27 (5.6 %)

1-Ann Saudi Med. 2007 Jan-Feb;27(1):1-5.

2- Saudi Med J. 2007 Dec;28(12)

3-Ann Saudi Med. 2013 Jan-Feb;33

HPV and cervical cancer

The detection rate of HPV in cervical cancer ranged from

70% to 100% and averaged 92.9% worldwide.

Worldwide, HPV16 and 18 resulted for more then 70% of

cervical cancer cases .

J Natl Cancer Inst. 1995

Br J Cancer. 2003

HPV prevalence

Nature Volume: 2012

cervical cancer in Saudi Arabia

One hundred specimens

The mean age 56 ±3.32 y (range20-94 years).

The rate of HPV genotype detection among cervical

cancer samples was 95.5%. HPV-16 (63.4%)

HPV-18 (11.1%)

HPV-45 (4.5%)

HPV-33 (3.3%)

HPV-31, HPV-52, HPV-53, HPV-58, HPV-59, and HPV-66 (2.2%)

Albadawi et al Int J Gynecol Cancer.2011 Jul

cervical cancer in saudi arabia

One hundred ( 82%) were positive for HPV sequences.

Most common genotypes were HPV-16 (71%), 31 (7%),

and 18, 45, 73 (4% each).

Alsebeih et al Infect Agent Cancer.2013


A total of 40 cervical samples

HPV infections were found in 43% .

The most prevalent genotypes were HPV 16 (30%) HPV

18 (8.0%) followed by type HPV 45 (5%)

Turki et al Asian Pac J Cancer Prev 2013

http://www.ncbi.nlm.nih.gov/pubmed/23803100







Total of 164 patients

Median Age of 46.5 years.

Stage-IA (3.0%)

IB (28.7%)

IIA (11.6%),

IIB (56.7%).

The cumulative five and ten year's survival for squamous

cancer patients was 68.3% and 57.9% respectively.

Only the status of parametrial involvement was

found to be of significance.

El-Senoussi et al ,Int J Radiat Oncol Biol Phys. 1998 Aug


Total of 504 patients

74% present with advanced disease

The overall 3, 5 and 10 years survival patients was 64%,

55% and 40%, respectively

Improvement in overall outcomes will require earlier

diagnosis, achievable only through an effective screening

program

Manji et al Eur J Gynaecol Oncol. 1999

Cervical cancer screening program in

Saudi Arabia : Action is overdue

FIGO(1991) BC(%) KFSH(%)

Stage I 38 58 20

Stage II 32 17 37

Stage III 26 20 29

Stage IV 4 5 14

Comparison of stage distribution

Manji etal .Annals of Saudi Medicine 2000


3 Years(%) 5 years(%)

FIGO(1991) 68 60

USA 68 63

UK _ 47

India _ 48

South Africa 57 41

Sweden 69 59

Canada 69 62

Saudi Arabia 64 55

Annals of Saudi Medicine 2000

Comparison of overall survival rate in various countries

Cervical cancer screening program in Saudi

Arabia : Action is overdue

The health services in the Kingdom of Saudi Arabia thus

have to consider launching nation wide public education

and screening programs.

These should include services such as colposcopy

clinics to manage the abnormalities detected during

the screening program.

Annals of Saudi Medicine 2000

Cervical Cancer Prevention in Saudi

Arabia: It is Time to Call for Action!

Objectives:

One aim of this review is to understand the current status of

cervical cancer in Saudi Arabia. Based on this information,

To formulate recommendations for cervical cancer

prevention that can be applied in our local setting.

Suggestions and Recommendations:

Screening should be started at a later age and should include

(HPV) testing.

The age of onset of screening should be determined

based on data collected regarding the age of sexual debut

for women.

Sait etal The Open Women’s Health Journal, 2012,

Budget for screening efforts is limited

Difficult access to health care

No follow up surveillance

Screening test must be very sensitive

Screening scheme ≤ two visits

If we don’t have establish screening program for cervical

cancer in low resources setting

what we will use ??

PAP

VIA

HPV testing

Subjective

Require regular training and monitoring

Requires high quality control .

The necessity for multiple visits with cytology based.

Even with the best quality control ,cytology has low

sensitivity

Sensitivity of PAP 53 %

Cuzick et al IGC 2006

VIA: Visual inspection with acetic acid

VILI: Visual inspection with Lugols iodine

Both Low tech can be done by nurses

May need to utilize colposcopy to triage post positive

test to rule out cancer

Country Sensitivity Specificity

Arbyn, 2008 Africa & India 79.2 84.7

Sarian, 2005 Argentina & Brazil 50.0 89.7

Perez-Cruz, 2005 Mexico 14.3 97.3

Al Monte, 2007 Peru 41.2 76.7

Murillo, 2010 Colombia 53.6 93.2

Arbyn et al., IJC 2008; Sarian et al., JMedScreen 2005,

Perez-Cruz et al., SalpublicaMex 2005,

Al Monte, IJC 2007,

Murillo et al., IJGO 2010

More sensitive than pap smear

Negative PV testing provides reassurance of not developing CIN3

over the next 5-10 years

HPV test is ideally suited to reassure the negative HPV individual

and to increase interval between two subsequent screens

Cytology vs HPV testing :variability of

cytological diagnosis

Sensitivity for CIN

Population No PAP HPV comb

Germany 7592 34% 86% 94%

UK 10,3358 72% 97% 100%

Mexico 6115 57% 94% 98%

Costa Rica 6176 80% 86% 92%

China 1936 94% 98% 100%

Baltimore 1040 60% 100 100%

Wright et al 2004 obs Gnecol

Sankaranarayanan,R:Total of 131,746 healthy women

ages of 30 and 59 years RCT ,4 Arms of screening tool in India

HPV test vs. Pap test vs. VIA vs. Observation

Cervical cancer as an endpoint

32000 women in each arm

Screen positive received colposcopy and treatment

Only significant screening method to reduce deaths from cervical

cancer was HPV testing

NEJM Apr2009 360(14)1385-94

CYTOLOGY

Lab

Organizer

GP

Time/travel

Program

Total

Cost €

21.77

11.23

11.76

6.01

2.08

52.85

HPV

Lab

Organizer

GP

Time/travel

Program

Total

Cost €

33.83

11.23

11.76

6.01

2.08

64.9

BJOG.2012

Write proposal with help of international advisor and

Local Epidemiologist

Decision to use HPV testing HC2 (high risk) in collaboration

of local virology lab

Design unique data base for the program with recalling

system

Quality assurance and frequent monitoring

Dr. Nisrin Anfinan

Early Detective

Unit and JCSP Coordinator

Rowaida Al Mehy

GOU Secretary

Maribi Marqueses

GOU Office Assistant

Dr. Faten Gazzaz

Director of

Virology Laboratory

Eman Tayba

JCSP Laboratory Team

Aseel Alsobehi


Soheel Melebari


Prof. Jim Bentley

International Advisor

Prof. Khalid Sait

Director of Scientific Chair of Professor Abdullah

Hussain Basalamah

Prof. Abdullah Hussain Basalamah

General Advisor

Targeted Population:

There are a total of 944,816 women at age of 30-

65 in Jeddah region.

Married for 3 year ??

Age 30-65 year.

Married for three years.

Saudi & non Saudi.

HR-HPV DNA in women 30 + years old

Negative

Negative

Negative

Pap test

Positive

Positive

Colposcopy

Positive

Repeat HR-DNA

testing @ 5 year

intervals till age

65

Repeat HR-

HPV testing at

12 months

Competency was maintained by medical

supervision in the field and by periodic supervision to monitor

their performance, along with rates of positive results on

screening

correlation between colposcopy and histologic findings, and

positive predictive values for CIN.

Double test with PCR ,Hc2

Campaign (malls)

School (approval from ministry of education )

Media and news papers

collecting sampling in our hospital )

Collecting Sample At PHC

Collecting Sample In Our Hospital

Collecting sample at PHC

Collecting sample in our hospital

King Abdulaziz university



Dr. Sami Badawwod




Dr. Sami Badawwod

To start in 40 PHC in Jeddah


HPV self sampling


Collecting sampling in our hospital

START DATE: January 2012

Total Number:2500

Our aim to achieve : 10,000 in four years

0

50

100

150

200

250

300

350

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1022

98

148168

56

3018

46

196

330

212

New Registration for Year 2012

0

50

100

150

200

250


128

188

162

196

126

88

8

60

208

96

60

8

New Registration for Year 2013

0

50

100

150

200

250


414

54

108

154

48

16 1422

152

218

144

6 8

44 40

14 8 144

24

44

112

68

New Registration for Year 2012 – Saudi vs. Non-Saudi

Saudi Non-Saudi

0

20

40

60

80

100

120

140

160


98

124

80

156

78

64

2

16

86

66

36

8

30

63

82

40 44

24

6

44

122

3024

0

New Registration for Year 2013 – Saudi vs. Non-Saudi

Saudi Non-Saudi

National

Cervical

Screening

Program

البراهينعلىالمبنيهالصحيهللرعايهالسعوديالمركز

Guideline meeting for cervical cancer

screening

Agreed among panel members that HPV testing will be

used as primary screening for cervical cancer in SA

Official opening of the program done yesterday

hosted by

Dr. Sami Badoud

National cervical screening program

in Saudi Arabia

Science

Dr nisreen anfnan cervical cancer in saudi arabia last version