Pre invasive

cervical lesions

in Egypt

Literature review Aboubakr Elnashar

Benha University Hospital

Aboubakr Elnashar

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

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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:

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Articles were grouped according to I. Screening organization

II. Prevalence

III. Risk factors

IV. Screening and diagnosis

V. Treatment

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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.

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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.

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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.

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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].

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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}.

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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.

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II. Prevalence

Wide variation ranging from

1% [El Mosselhy et al; 1998]

8% [Abd El All 1992.]

In ages from 20–60 ys.

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CIN

(%)

No Study University Year Author

1.07 4458 Hospital Cairo 1987 Hammad et al

3.1 5453 Community Suez canal 2007 Abd El All et al

3.1 25522 Hospital Ain Shams 2004-

2010

Shalakany

(2012)

7.7 3600 Hospital Minia 2014 Sanad et al

Prevalence of CIN in Egypt (Elnashar, 2014)

Invasive cx ca in Egypt:

0.04% (AbdelAll et al, 2007)

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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.

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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}.

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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

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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}

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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

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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

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IV. Prolonged use of progestagen-only

contraceptives

(Darwish et al, 2004) not associated with increased risk of abnormal

cytologic findings.

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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%.

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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.

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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

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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

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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.

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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.

VILI VIA Cytology

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

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.

UNEE Cytology Colposcopy

80% 60% 86.7% Sensitivity

84.2% 91.2% 83.1% Specificity

3.8% 100% 20% PPV

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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

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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].

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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

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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.

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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

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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

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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

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Thank you Face book: Aboubakr Elnashar lectures

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