CIN in Egypt


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CIN in Egypt

  1. 1. Pre invasive cervical lesions in Egypt Literature review Aboubakr Elnashar Benha University Hospital Aboubakr Elnashar
  2. 2.  Objective: To study pre invasive cervical lesions in Egypt regarding: screening organization, prevalence, risk factors, screening and diagnosis and treatment  Methods: A literature search was conducted in Pubmed, High wire, Scopus. Key words: Egypt, CIN, Premalignant, Screening Aboubakr Elnashar
  3. 3. Total number of citations (dated 1965−2014) n=60 Citation excluded after screening titles and/or abstract n=31 Full manuscript retrieved for detailed evaluation n=29 Article excluded n=2 (reasons case series, reports, letter) Articles included for review of evidence n=27 Results: Aboubakr Elnashar
  4. 4.  Articles were grouped according to I. Screening organization II. Prevalence III. Risk factors IV. Screening and diagnosis V. Treatment Aboubakr Elnashar
  5. 5. I. Screening organization Cytologic screening: mainly performed on an opportunistic basis. No national screening program: Only sporadic reports regarding the prevalence {costs associated with universal screening} Opportunistic screening: At university and teaching hospitals When there is a clinical suspicion of cervical lesion. Aboubakr Elnashar
  6. 6. The first organized screening established at the Ain Shams University in the Early Cancer Detection Unit in 1981 [Fahim et al, 1991]. Following this other universities and teaching hospitals in various governorates started similar units. Aboubakr Elnashar
  7. 7. Most screening testing: women from lower social classes attending for other gynecologic problems Women from rural areas have difficulties in accessing such services [Shalakamy, 2012]. The cost of screening and treatment not covered by public funding. Aboubakr Elnashar
  8. 8. Quality assurance of cytology-colposcopy service: lacking. Sensitivity of cytology- based screening: less than satisfactory (14.4–22.7%) [Fahim et al, 1991]. Inadequacy of existing cytology-based screening services. 1. Lack of regular state funding 2. Deficiency in supervised training 3. Absence of regular review/auditing of practice 4. Sub-threshold workload [Shalakamy, 2012]. Aboubakr Elnashar
  9. 9. Obstacles for the implementation of mass screening (Sancho-Garnier, et al 2012) 1. lack of real political understanding to support such public health programs and provide the necessary resources. 2. The absence of appropriate political will {low incidence of cervical cancer existing opportunistic screening lack of interest amongst healthcare professionals}. Aboubakr Elnashar
  10. 10. 3. Lack of awareness and knowledge among women, coupled with socio-cultural barriers and difficulties in accessing medical services all hinder the participation of women in cervical screening. 4. Limited resources to perform cytology- based screening is a major impediment. That is why VIA is being experimented as an alternative first approach to organized screening. 5. Management of abnormal Pap smears (or any other screening test) and the diagnosis and treatment procedures (colposcopy, biopsy, surgery): poorly developed and are not quality controlled. Aboubakr Elnashar
  11. 11. II. Prevalence Wide variation ranging from 1% [El Mosselhy et al; 1998] 8% [Abd El All 1992.] In ages from 20–60 ys. Aboubakr Elnashar
  12. 12. CIN (%) No StudyUniversityYearAuthor 1.074458HospitalCairo1987Hammad et al 3.15453CommunitySuez canal2007Abd El All et al 3.125522HospitalAin Shams2004- 2010 Shalakany (2012) 7.73600HospitalMinia2014Sanad et al Prevalence of CIN in Egypt (Elnashar, 2014) Invasive cx ca in Egypt: 0.04% (AbdelAll et al, 2007) Aboubakr Elnashar
  13. 13. III. Risk factors The awareness of the Egyptian women by Risk factors: extremely low (Abdelall et al, 2007) HPV: very low Smoking, hormones, and infections: main risk factors. Aboubakr Elnashar
  14. 14. I. The socio-economic Main risk factors (Abdelall et al, 2007) Still menstruating (p <0.001) Unskilled workers (p<0.0001) Middle income Married With 3 or more children Mostly uneducated Early marriage or early sexual relations not significantly associated with HPV {Egyptian women start sexual relations with marriage}. Aboubakr Elnashar
  15. 15. II. Infections 1. HPV Main subtypes: 16/18 and 31/33 (Abdelall et al. 2007; Elorbany et al 2011; Abd El-Azim et al 2011; Elkharashy et al 2013) HPVs infection: more pronounced in (Abdelall et al. 2007) younger age actually married still menstruating ever used hormonal or vaginal contraceptives unskilled workers Aboubakr Elnashar
  16. 16.  Recommendation: 1. HPV DNA detection and genotyping for classifying oncogenic HPV (Sharaf et al 2012; Elkharashy et al 2013) 2. HPV vaccination (Abd El-Azim et al 2011; Elorbany et al 2011) 2nd generation polyvalent HPV vaccines. {HPV-33 and HPV-31 being 2nd and 3rd most prevalent genotypes after HPV-16} Aboubakr Elnashar
  17. 17. 2. Chlamydia T (el-Ahl et al, 2002) Risk factors in Egyptian studies. 3. T. vaginalis (el-Ahl et al, 2002) Previously implicated Not established in the actual work. 4. Schistosomiaisis [Abd El All et al, 1992; Youssef et al 1970] Risk factor for the development of ca cx Aboubakr Elnashar
  18. 18. III. Women undergoing hysterectomy (Abd El-Moaty & Hegazy, 2009) CIN: 7.2% 1. Pap test as routine preoperative investigations. 2. After subtotal hysterectomy: cytological follow up Aboubakr Elnashar
  19. 19. IV. Prolonged use of progestagen-only contraceptives (Darwish et al, 2004) not associated with increased risk of abnormal cytologic findings. Aboubakr Elnashar
  20. 20. IV. Screening and diagnosis I. Cytology 1. Hammad et al (1987) 4458 patients evaluated by cytology From 1981 to 1985 2. Fahim et al (1991) Association between age of women, parity, age at marriage and duration of marriage and the sensitivity and specificity of Pap smear. 3. El-Shalakany et al (2004) Cytology: Sensitivity: 16.9% Specificity: 97.8% PPV: 23.3%. Aboubakr Elnashar
  21. 21. 4. Abd El All et al (2007) Only 1.5% of studied women had Pap smear. {absence of health culture}. Screening for all women Once every 10 years for women with normal cytological findings yearly for three successive years for inflammatory changes. Aboubakr Elnashar
  22. 22. II. HPV 1. Abdelaziz et al (2006) HPV testing is a useful tool when combined with cytology in the diagnosis of high-risk HPV viral types in apparently normal tissues. 2. Shalaby et al (2007) 5% of patients with positive HPV DNA results had negative follow-up biopsy result. False-negative" biopsies accounted for one third of cases Aboubakr Elnashar
  23. 23. III. VIA 1. Elnashar et al (1999): NEAA  PPV: 66.7% Pap. Smear: 84 % NEAA:  inexpensive, easy  alternative to Pap smear  can detect 66.7 % of high-grade SIL Aboubakr Elnashar
  24. 24. 2. El-Shalakany et al (2004) VIA: superior sensitivity compared with cytology primary screening tool with a satisfactory low biopsy rate in low-resource settings 3. Abdel-Hady et al (2006) Relatively high rate of false-positive, valuable test for the screening of cx ca 4. Sanad et al (2014) can be used in national programs for cx ca screening. Aboubakr Elnashar
  25. 25. IV. VILI: El-Shalakany et al (2008) VILI: Easy to perform Superior sensitivity to cervical cytology and VIA An efficient primary screening tool Satisfactory low biopsy rate in low resources settings. VILIVIACytology 97.7%90.9%22.7%Sensetivity 94.8%94.6%97.6%Specificity 46.2%43.5%41.7%PPV 99.9%99.6%96.6%NPV Aboubakr Elnashar
  26. 26. V. Unaided naked-eye examination Darwish et al (2013) NPV of the 3 tests were nearly comparable. UNEE an acceptable alternative for screening for CIN or malignant lesions especially in low-resource settings. UNEECytologyColposcopy 80%60%86.7%Sensitivity 84.2%91.2%83.1%Specificity 3.8%100%20%PPV Aboubakr Elnashar
  27. 27. VI. Gynoscopy= VIA M Darwish et al (2014) A simple hand held lens with a magnifying power of +4D to visualize the cervix after application of acetic acid Improves most of diagnostic indices Simple Cheap Acceptable Aboubakr Elnashar
  28. 28. VII. Treatment Three visits strategy one for screening one for colposcopy, one for treatment: poor compliance, especially among rural women. Colposcopic see-and-treat strategy Centers in Assiut and Delta: satisfactory results no significant extra morbidity [Emam et al, 2009]. Aboubakr Elnashar
  29. 29. I. LEEP Edessy et al (2013) LEEP Cure rates CINI: 96.7%, CINII: 88.9% CINIII: 80%  minimal complications good cure rates especially in those with CINI Aboubakr Elnashar
  30. 30. II. Single-step diagnosis and treatment 1. Darwish and Gadallah (1998) practical and fast limited complications eliminating 2nd session of tt. save time and resources Advantages, particularly in developing countries, may outweigh the high overtreatment rate. Aboubakr Elnashar
  31. 31. 2. Emam et al (2009) appropriate in low-resource countries. See and treat strategy 3 Visits strategy 16%15.8%Over treatment rate 20.8%0.0%Drop out rate Aboubakr Elnashar
  32. 32. Recommendations 1. Resource allocation for routine screening through:  Health insurance  Service delivery to rural areas and slum 2. Raising awareness of Egyptian women on risk factors of ca cx through health communication programs Aboubakr Elnashar
  33. 33. 3. Integrating cervical screening into  Primary care centers  Antenatal clinic  Contraceptives services 4. Application of  VIA when vaginal examination  See-and-treat strategy  Quality improvement Aboubakr Elnashar
  34. 34. Thank you Face book: Aboubakr Elnashar lectures Aboubakr Elnashar