The document discusses cervical cancer in Saudi Arabia. It finds that incidence of cervical cancer is low in Saudi Arabia, ranking 11th among cancers in females, with 152 new cases and 55 deaths per year. HPV is detected in 31.6-5.6% of women in Saudi Arabia. Nearly all cervical cancer cases (92.9-100%) are associated with HPV infection, most commonly HPV 16 and 18. The document calls for a nationwide cervical cancer screening program in Saudi Arabia, as the actual reasons for low incidence are unknown without screening. It proposes a screening program using HPV testing to screen women ages 30-65 every 5 years until age 65.

1. Cervical cancer in Saudi Arabia
Dr. Nisreen Anfinan

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. 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. Cancer in Saudi Arabia
SCR Report 2009

5. Age specific incidence rate for cancer cervix
in SA
SCR Report 2009

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. 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. 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. 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. 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. 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. 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. HPV prevalence
Nature Volume: 2012

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. 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. 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. 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. 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. 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. 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. 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. 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.  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. If we don’t have establish screening program for cervical
cancer in low resources setting
what we will use ??
 PAP
 VIA
 HPV testing

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.  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. 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.  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. 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. 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. 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.  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. 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. Targeted Population:
 There are a total of 944,816 women at age of 30-
65 in Jeddah region.
 Married for 3 year ??

35.  Age 30-65 year.
 Married for three years.
 Saudi & non Saudi.

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.  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

41.  Campaign (malls)
 School (approval from ministry of education )
 Media and news papers

42. collecting sampling in our
hospital )

43. Collecting Sample At
PHC
Collecting Sample In
Our Hospital

44. Collecting sample
at PHC
Collecting sample
in our hospital
King Abdulaziz university

45. Collecting sample
at PHC
Collecting sample
in our hospital
Dr. Sami Badawwod
King Abdulaziz university

46. Collecting sample
at PHC
Collecting sample
in our hospital
Dr. Sami Badawwod
To start in 40 PHC in Jeddah
King Abdulaziz university

47. HPV self sampling
Collecting sample
at PHC
Collecting sampling
in our hospital

48.  START DATE: January 2012
 Total Number:2500
 Our aim to achieve : 10,000 in four years

49. 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

50. 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

51. 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

52. 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

53. National
Cervical
Screening
Program

54. ‫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

55. Official opening of the program done yesterday
hosted by
Dr. Sami Badoud

56. National cervical screening program
in Saudi Arabia