Post on 14-Jun-2015
+
Dr. Nisreen Anfinan
+
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
+
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
+
Normal Cervix
HPV Infection
Cervical Dysplasia
Cervical Cancer
Primary
Prevention:
Vaccination
Secondary
Prevention:
Screening
+
PAP smear
VIA
HPV testing
+
+
+
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.
+ 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
+
Budget for screening efforts is limited
Difficult access to health care
No follow up surveillance
Screening test need to be very sensitive
+
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
+
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.
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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
+
+
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
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Comment Specificity Sensitivity Method
Easy, relatively inexpensive, but subjective,
insensitive, and nonspecific Low Cytology
Radioactive, commercially available as
ViraPap, ViraType, HPV Profile; labor intensive Moderate Dot blot
Rarely used today Low Filter in situ hybridization
Detects HPV in paraffin-embedded tissue Moderate In situ hybridization
Gold standard but cumbersome; not feasible
for large-scale clinical use High Southern blot hybridization
Newly approved for commercial use;
nonradioactive, easier to use and less
expensive than dot blot
High Hybrid capture
Uses amplification and so is prone to
contamination errors (false positive) High Polymerase chain reaction
Spitzer, Am J Obstet Gynecol, 1998
+
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
+
PAP HPV
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
+
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
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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
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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
+
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
+
Targeted Population:
There are a total of 944816 women at age of 30-65
in Jeddah region.
Married for 3 yearr ??
+
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
+
Age 30-65 year.
Married for three years.
Saudi & non Saudi.
+
+
+
+
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
+
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
+
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
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Collecting sample at PHC
Collecting sample in our hospital
Dr. Sami Badawwod
To start in 40 PHC in Jeddah
King Abdulaziz university
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HPV self sampling
Collecting sample at PHC
Collecting sampling in our hospital
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البراهين على المبنيه الصحيه للرعايه السعودي المركز
Guideline meeting for cervical cancer screening
Agreed among panel members that HPV testing will be used as primary screening for cervucal cancer in SA
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+
START DATE:
Total Number:
Our aim to achieve :
+
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
+
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
+
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
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
+
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
+
In January 2014 will release
our positive HPV data.
Official opening of the
program will be hosted by
Dr. Khoshaim Mohmade.
+
National
Cervical
Screenin
Program