Cervical cancer in Saudi Arabia Dr. Nisreen Anfinan
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
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
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
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
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
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
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
Cervical cancer in Saudi Arabia
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
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
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
Collecting sample at PHC
Collecting sample in our hospital
Dr. Sami Badawwod
King Abdulaziz university
Collecting sample at PHC
Collecting sample in our hospital
Dr. Sami Badawwod
To start in 40 PHC in Jeddah
King Abdulaziz university
HPV self sampling
Collecting sample at PHC
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
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
0
50
100
150
200
250
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
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
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
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