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  • 1. + Dr. Nisreen Anfinan
  • 2. + Cancer Incidence Report Saudi Arabia 2007. Available at www.scr.org.sa/reports/SCR2007.pdf Accessed on June 26, 2011 Prevalence: 2,274,000 women have cervical cancer1 Incidence: 510,000 new cases each year1 14,845 United States/Canada 49,025 South America 67,078 Africa 1,077 Australia/New Zealand 64,928 Europe 151,297 Southcentral Asia
  • 3. + 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 1.9 cases per 100,000 women, accounting for 2.6% of diagnosed cancer cases in women Cancer Incidence Report Saudi Arabia 2007. Available at www.scr.org.sa/reports/SCR2007.pdf Accessed on June 26, 2011
  • 4. + Normal Cervix HPV Infection Cervical Dysplasia Cervical Cancer Primary Prevention: Vaccination Secondary Prevention: Screening
  • 5. +  PAP smear  VIA  HPV testing
  • 6. +
  • 7. +
  • 8. +  Sensitivity of pap test to detect CIN3+: 55%.  Should be done in the context of an organized screening program.  Quality assurance of cytology needs to be very good.  System of communication to the women screened so that they may receive sufficient treatment.  Requires colposcopy and biopsy to confirm dysplasia.  The necessity for multiple visits with cytology based.  Screening results in significant loss to follow-up.
  • 9. + I f we don’t have establish screening program for cervical cancer in low resources setting what you will use ?? Visual inspection of ascitic acid (VIA ) or HPV testing
  • 10. + Budget for screening efforts is limited Difficult access to health care No follow up surveillance Screening test need to be very sensitive
  • 11. + 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
  • 12. + TEST SENSITIVITY (%) SPECIFICITY (%)* POSITIVE PREDICTIVE VALUE (%)* NEGATIVE PREDICTIVE VALUE (%)* VIA (n = 2,130) 77 (70–82) 64 (62–66) 19 96 Pap smear (n = 2,092) 44 (35–51) 91 (37–51) 33 94 University of Zimbabwe/JHPIEGO Cervical Cancer Project 1999.
  • 13. + 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
  • 14. +
  • 15. + Triage equivocal or low grade cytology smears (ALTS trial). FUP of women with abnormal cytology but normal colposcopy. Predict outcome after treatment of high grade disease. Primary Screening. Cuzick J. Vaccine 2008
  • 16. + CommentSpecificitySensitivityMethod Easy, relatively inexpensive, but subjective, insensitive, and nonspecific LowCytology Radioactive, commercially available as ViraPap, ViraType, HPV Profile; labor intensive ModerateDot blot Rarely used todayLowFilter in situ hybridization Detects HPV in paraffin-embedded tissueModerateIn situ hybridization Gold standard but cumbersome; not feasible for large-scale clinical use HighSouthern blot hybridization Newly approved for commercial use; nonradioactive, easier to use and less expensive than dot blot HighHybrid capture Uses amplification and so is prone to contamination errors (false positive) HighPolymerase chain reaction Spitzer, Am J Obstet Gynecol, 1998
  • 17. +  More sensitive than pap smear  Negative PV testing provides reassurance of not developing CIN3 over the next 5-10 years  High HPV permits a safe and cost effective lengthing of the interval 5 years  HPV test has an high NPV  HPV test is ideally suited to reassure the negative HPV individual and to increase interval between two subsequent screens
  • 18. + PAPHPV 55.6%94.6%Sensitivity 96.8%94.1%Specificity Mayrand et al.; compare the relative efficacy of HPV DNA testing and Pap cytology in primary screening for cervical cancer and its high-grade precursors. Pap screening followed by HPV (hc 2) vs hc2 testing followed by HPV in women 30-69  9,667 women HPV testing is significantly more sensitive to detect CIN 2+ NEJM 2007
  • 19. + 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  Significant reduction in Ca Cervix in the HPV negative compared to negative Pap and VIA NEJM Apr2009 360(14)1385-94
  • 20. + National Programmers Pilot Studies Argentina Germany Nicaragua Mexico China Paraguay The Netherlands Colombia Peru USA El Salvador Georgia Spain Rwanda India Uganda Italy United Kingdom
  • 21. + 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 May;119(6):699-709. doi: 10.1111/j.1471-0528.2011.03228.x. Epub 2012 Jan 18
  • 22. + 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
  • 23. + Targeted Population: There are a total of 944816 women at age of 30-65 in Jeddah region. Married for 3 yearr ??
  • 24. + 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
  • 25. + Age 30-65 year. Married for three years. Saudi & non Saudi.
  • 26. +
  • 27. +
  • 28. +
  • 29. + Use the high sensitivity of HPV test initially Digene Hybrid capture 2 test is suitable Positive HPV test has reflex pap testing If both positive colposcopy is performed If HPV neg repeat screen in 5 years If HPV +ve and pap neg, repeat HPV and pap in 1 year
  • 30. +  Provider 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.  Internal and external quality-control measures were in place for colposcopy and pathological analysis
  • 31. + Campaign (malls) School (approval from ministry of education ) Media and news papers
  • 32. + collecting sampling in our hospital )
  • 33. + Collecting Sample At PHC Collecting Sample In Our Hospital
  • 34. + Collecting sample at PHC Collecting sample in our hospital Dr. Sami Badawwod To start in 40 PHC in Jeddah King Abdulaziz university
  • 35. + HPV self sampling Collecting sample at PHC Collecting sampling in our hospital
  • 36. + ‫المركز‬‫السعودي‬‫للرعايه‬‫الصحيه‬‫المبنيه‬‫على‬‫البراهين‬ Guideline meeting for cervical cancer screening  Agreed among panel members that HPV testing will be used as primary screening for cervucal cancer in SA
  • 37. +
  • 38. + START DATE: Total Number: Our aim to achieve :
  • 39. + 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
  • 40. + 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
  • 41. + 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
  • 42. + 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
  • 43. + 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
  • 44. + In January 2014 will release our positive HPV data. Official opening of the program will be hosted by Dr. Khoshaim Mohmade.
  • 45. + National Cervical Screenin Program