Dr nisreen anfnan cervical cancer in saudi arabia last version

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Dr nisreen anfnan cervical cancer in saudi arabia last version

  1. 1. Cervical cancer in Saudi Arabia Dr. Nisreen Anfinan
  2. 2. 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
  3. 3. 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
  4. 4. Cancer in Saudi Arabia SCR Report 2009
  5. 5. Age specific incidence rate for cancer cervix in SA SCR Report 2009
  6. 6. Cervical cancer in Saudi Arabia  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
  7. 7. Authora Duration Total no Abnormal PAP smear ASC-US ASC-H LSIL HSIL AGUS INVASIVE CANCER Al-Jaroudi (1) 2008 – 2009 241 7 (2.9%) 3 (1.2%) 1 (0.4%) 2 (0.83%) NR 1 (0.4%) NR Jamal (2) 1984 – 2000 22089 368 (1.66%) 88 (0.4%) NR 81 (0.37%) 72 (0.32%) 36 (0.16%) 26 (0.1%) Altaf (3) 2001 3088 97 (3.14%) 14 (0.45%) NR 29 (0.93%) 17 (0.55%) 4 (0.13%) 5 (0.16%) Abdullah L (4) 1998 – 2005 5590 261 (4.7%) 103 (1.84%) 6 (0.10%) 5 (0.09%) 31 (0.55%) 30 (0.53%) 2 (0.04%) Altaf(5) 2000 – 2004 5132 241 (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
  8. 8. Authora Duration Total no Abnormal PAP smear ASC-US ASC-H LSIL HSIL AGUS INVASIVE CANCER Al-Jaroudi (1) 2008 – 2009 241 7 (2.9%) 3 (1.2%) 1 (0.4%) 2 (0.83%) NR 1 (0.4%) NR Jamal (2) 1984 – 2000 22089 368 (1.66%) 88 (0.4%) NR 81 (0.37%) 72 (0.32%) 36 (0.16%) 26 (0.1%) Altaf (3) 2001 3088 97 (3.14%) 14 (0.45%) NR 29 (0.93%) 17 (0.55%) 4 (0.13%) 5 (0.16%) Abdullah L (4) 1998 – 2005 5590 261 (4.7%) 103 (1.84%) 6 (0.10%) 5 (0.09%) 31 (0.55%) 30 (0.53%) 2 (0.04%) Altaf(5) 2000 – 2004 5132 241 (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
  9. 9. 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.
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. HPV prevalence Nature Volume: 2012
  14. 14. 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
  15. 15. 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
  16. 16. Cervical cancer in Saudi Arabia  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
  17. 17. Cervical cancer in Saudi Arabia  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
  18. 18. Cervical cancer in Saudi Arabia  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
  19. 19. 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
  20. 20. Cervical cancer in Saudi Arabia 3Years(%) 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
  21. 21. 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
  22. 22. 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 etalThe Open Women’s Health Journal, 2012,
  23. 23.  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
  24. 24. If we don’t have establish screening program for cervical cancer in low resources setting what we will use ??  PAP  VIA  HPV testing
  25. 25.  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
  26. 26.  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
  27. 27. 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
  28. 28.  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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32.  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
  33. 33. 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 JCSP Laboratory Team Soheel Melebari JCSP Laboratory Team Prof. Jim Bentley International Advisor Prof. Khalid Sait Director of Scientific Chair of Professor Abdullah Hussain Basalamah Prof. Abdullah Hussain Basalamah General Advisor
  34. 34. Targeted Population:  There are a total of 944,816 women at age of 30- 65 in Jeddah region.  Married for 3 year ??
  35. 35.  Age 30-65 year.  Married for three years.  Saudi & non Saudi.
  36. 36. 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
  37. 37.  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
  38. 38.  Campaign (malls)  School (approval from ministry of education )  Media and news papers
  39. 39. collecting sampling in our hospital )
  40. 40. Collecting Sample At PHC Collecting Sample In Our Hospital
  41. 41. Collecting sample at PHC Collecting sample in our hospital King Abdulaziz university
  42. 42. Collecting sample at PHC Collecting sample in our hospital Dr. Sami Badawwod King Abdulaziz university
  43. 43. Collecting sample at PHC Collecting sample in our hospital Dr. Sami Badawwod To start in 40 PHC in Jeddah King Abdulaziz university
  44. 44. HPV self sampling Collecting sample at PHC Collecting sampling in our hospital
  45. 45.  START DATE: January 2012  Total Number:2500  Our aim to achieve : 10,000 in four years
  46. 46. 0 50 100 150 200 250 300 350 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 10 22 98 148 168 56 30 18 46 196 330 212 New Registration for Year 2012
  47. 47. 0 50 100 150 200 250 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 128 188 162 196 126 88 8 60 208 96 60 8 New Registration for Year 2013
  48. 48. 0 50 100 150 200 250 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 4 14 54 108 154 48 16 14 22 152 218 144 6 8 44 40 14 8 14 4 24 44 112 68 New Registration for Year 2012 – Saudi vs. Non-Saudi Saudi Non-Saudi
  49. 49. 0 20 40 60 80 100 120 140 160 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 98 124 80 156 78 64 2 16 86 66 36 8 30 63 82 40 44 24 6 44 122 30 24 0 New Registration for Year 2013 – Saudi vs. Non-Saudi Saudi Non-Saudi
  50. 50. National Cervical Screening Program
  51. 51. ‫المركز‬‫السعودي‬‫للرعايه‬‫الصحيه‬‫المبنيه‬‫على‬‫البراهين‬  Guideline meeting for cervical cancer screening  Agreed among panel members that HPV testing will be used as primary screening for cervical cancer in SA
  52. 52. Official opening of the program done yesterday hosted by Dr. Sami Badoud
  53. 53. National cervical screening program in Saudi Arabia

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