CIN in Egypt
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Pre invasive
cervical lesions
in Egypt
Literature review Aboubakr Elnashar
Benha University Hospital
Aboubakr Elnashar
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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
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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
Aboubakr Elnashar