18- dr. ghazi alsbeih kau 13 may 2015

1. HPV in Cervical & other
Cancers in Saudi Arabia
Ghazi Alsbeih, MD, PhD
King Faisal Specialist Hospital & Research Centre,
Riyadh, Saudi Arabia
The 1st Scientific Meeting of Cancer Care for General Gynecology
Chair Abdullah Basalamah for Gynecological Cancers, Jeddah, 13-14 May 2015

2. Overview from 3 published research papers:
More work in progress ….

3. * Cancer is a complex, multistep process involving , lifestyle,
environmental, genetic predisposing factors & possible
infectious agents that promote carcinogenic transformation.
* Worldwide 17-18% of cancers
are related to infectious
diseases (Africa 25% - 10% in
developed world), second
only to tobacco use.
* Certain bacteria and parasites
are suspected to have a
carcinogenic effect.
* Viruses are one of the most
important risk factors for
cancer development in
humans.
Introduction
http://cancerhelpinghand.com/wp-content

4. HPV (Human Papilloma Virus)
 Virus that causes diseases in humans
ranging from common warts to cancer.
 Non enveloped virus, ~8000 bp circular
DNA, encodes for 6 early (E) proteins
responsible for virus replication and 2
late (L) structural proteins.
 Infectious cycle mainly in squamous
epithelia.
 > 200 subtypes with 120 infect human.
 30-40 subtypes infect the genital area of
women and men.
 Subtypes divided into 2 groups:
 Low risk causing warts: as HPV 6, 11.
 High risk causing cancer: 15 oncogenic
types mainly HPV 16 and 18.

5. Human PapillomaVirus (HPV) is implicated in several types
of human carcinomas including:
Known:
• Cervix uterine (96%) and
• Other anogenital (60%),
• Subgroup of Head & Neck (30%)
Potential: Subgroup of
• Colorectal (33% HPV+?)
• Breast (26% HPV+?)
Extrapolation in Saudi Arabia:
• HPV-related cancers would represent about 10% of all
cancers in both genders.
HPV-mediated cancers and Potential burden in
Saudi Arabia
0 10 20 30 40 50 100
Cancergroup
Breast
Anogenital
Colorectal
Head & Neck
None HPV-Mediated
Potentialy HPV-Mediated
All HPV-Mediated
Anogenital
Head & Neck
Colorectal
Breast
Potentially HPV+
HPV -
Total cancers in KSA (%)
0 10 20 30 40 50 100
All HPV-Mediated
Cancergroup

6. • Cervical Cancer is the 3rd most common cancer among
women worldwide, after breast and colorectum cancers.
• It accounts for 8.8% of all cancers in women.
The global cervical cancer incidence
in females:
(females)
GLOBOCAN 2008:
Source: http://globocan.iarc.fr
• The most common malignancies in women worldwide:
3rd

7. • The most common malignancies in human worldwide:
(males+females)
GLOBOCAN 2008:
The global cancer incidence in males
and females:
• Cervical Cancer is the 7th most common cancer in
human worldwide.
• It accounts for 4.2% of all cancers.
7th

8. Cervical cancer
ranks # 2 in developing- and # 7 in developed countries
In developed countries, the widespread screening using Pap smear has
dramatically (70%) reduced cervical cancer incidence and mortality
Developed
countries
1
2
3
4
5
6
7th
8
9
10
11
12
13
14
15
Developing
countries
1
2nd
3
4
5
6
7
8
9
10
11
12
13
14
15
GLOBOCAN 2008
Discrepancy between developing & developed
countries:

9. Cervical Cancer in Saudi Arabia:
• Cervical cancer ranks # 12
between all cancers in
females and accounts only
for 2.4% of all new cases.
• This is even lower than in
developed countries
despite the absence of
national screening
programs.
• The causes of this low
incidence are unknown
but suggests the presence
of protective variables
between known risk
factors for its development.
1
2
3
4
5
6
7
8
9
10
11
12th
13
14
15
Most common cancers in Saudi women
GLOBOCAN 2008

10. Risk factors for cervical cancer:
EM of HPV
• Most important: infection with human papillomavirus
(HPV: + in 85-99%), specially high risk (HR) HPV 16,
18, 31, 33, 45.
• Co-factors include:
 sexual activity at early age,
 number of sexual partners,
 uncircumcised males partner,
 multiple pregnancies,
 long term oral contraceptive,
 smoking,
 Chlamydia, HIV infection,
 impaired immune response,
 diet,
 low SES,
 family history
 genetic predisposition.
HPV
Virus

11. HPVs mechanisms of transformation:
• E6 and E7 oncoproteins of high-risk HPVs bind and degrade
TP53 and pRB controllers of cell cycle checkpoint causing
cell over-proliferation and genome instability.
p53
E6AP E6
U
p53
E6AP
E6
p53
p53
ViralCellular
U U
U
Erratic
cell
division
U
Degradation

12. Notes for HPV risk factor for cervical cancer:
• HPV is common, most infections clear
spontaneously.
• Only persistent HR HPV infection constitutes a risk.
• Only small proportion of HPV infected women
develops cervical cancer.
• Conservative societies are less subjected to HPV
infection?!
• Inconsistency between conservative countries
point out toward genetic, cultural & environmental
differences.

13. Prevalence of HPV Infection in Saudi Arabia
* Worldwide prevalence of HPV
in women varies among
studies and countries from
1.5% to 39% and closely
reflects age and sexual
activity.
* In KSA: 2 early limited
studies and many more
recent indicated prevalence
between 6% - 32% in cervical
swabs of women attending
routine exam.
* Most infections (80% – 90%)
are with high risk HPV16-18.

14. • The studies included so far 174 patients:
• Age at diagnosis: 28-106, median 46 years/old.
• Stage of the disease ranged between IA and IVA.
• 3 single women.
• Multiple pregnancies (median 7 live births).
• 11 patients reported other past cervical infections
• 6 only had prior screening.
• Histology: - squamous 79%
- adenocarcinoma 21%
• Age distribution by 5-year
age group shows biphasic
occurrence that peaks at
41-45 and 56-60 years old. Age group
26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-106
Numberofpatients
0
10
20
30
40
50
Adenocarcinoma
Squamous cell ca.
HPV in Invasive Cervical Cancer in KSA

15. Examples of HPV results along with negative and positive controls
HPV Detection and Genotyping
- +16
ControlHPV
Genotype: 311818
16
51
16
39
1633
52 45 59
16
8259
45
64
16
70 73
A total of 15 different HPV genotypes, present in single
and double infections, were detected in 174 patients.

16. Prevalence of HPVs infections and genotypes
• 83.33% were HPV+ (world: 85-99%).
• 15 HPV genotypes detected:
* 12 high risk: 16, 18, 31, 33, 39, 45,
51, 52, 56, 59, 73, 82 (IS39)
* 3 low risk: 6, 64, 70.
• 15 double infections: mainly 16 & 18
and 31, 33, 39, 45, 51, 52, 59, 70 & 82.
• The most common genotypes:
* 16 (66.2%) 31 (6.9%)
* 45 (5.5%) 18 (4.8%)
• With double infections: HPV-18
became the 2nd most common
genotype (8.13%).
The most common genotype by far is HPV-16
(68%) followed by HPV-18 (8%) that affected
together 80% of all positive patients
No HPV: 17%
HR HPV: 73%
LR HPV: 2%
DI HPVs 8%
HPV -/+,
high/low risk &
double infections
HPV16: 66.2%
HPV31:6.9%
HPV45:5.5%
HPV18:4.8%
HPV16-18:4.1%
HPV73:2.1%
HPV59:1.4%
HPV16-45:1.4%
HPV64:1.4%
HPV:56, 16-31,16-39, 16-51, 16-82,16-70, 33-52, 45-59, 6
0.7%:

17. • HPV-16/18 were equally frequent in younger (<46) and older
age (≥46) groups (34.48% compared to 32.18%, respectively).
There was no significant difference in the median age at
diagnosis of HPV-16/18 infected, other HPV genotypes or HPV
negative groups (P > 0.05).
HPVs Distribution by Age of Patients
Age group
26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-106
Numberofpatients
0
10
20
30
40
50
No HPV
HPV6
HPV16
HPV18
HPV31
HPV45
HPV59
HPV64
HPV73
HPV16/18
HPV16/39
HPV16/51
HPV16/70
HPV45/59
HPV16/51
HPV16/70
HPV16/82
HPV33/52
HPV45/59
All 174 patients
Age group
26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-106
Numberofpatients
0
10
20
30
40
HPV6
HPV16
HPV18
HPV31
HPV45
HPV56
HPV59
HPV64
HPV73
HPV16/18
HPV16/31
HPV16/39
HPV16/45
HPV16/51
HPV16/70
HPV16/82
HPV33/52
HPV45/59
145 HPV+ patients

18. • ~75% HPV-16 integrated in invasive cervical cancer
HPV Integration in HPV-16+ invasive cervical cancer
• Real-time PCR amplification curves of HPV-16 targeted
sequences of E2 and E6 genes.
81 HPV-16+
invasive
cervical
cancer
samples.

19. • So far, 108 head & neck
cancer samples were
processed
• HPV results were
obtained using the Linear
Array HPV Genotyping
Test (Roche Diagnostics),
showing negative (– C)
and positive (+ C)
controls positive
pathological sample of
cervix carcinoma.
HPV in Head & Neck Cancer in KSA
The 108 oropharyngeal cancers were all HPV-negative.

20. Breast Cancer:
% of HPV+ (ave.) 32.70%
Lowest % of HPV+ 4.47%
Highest % of HPV+ 86.21%
Colorectal Cancer:
% of HPV+ (ave.) 25.60%
Lowest % of HPV+ 14.20%
Highest % of HPV+ 84.00%
Reviewed publications on
HPV detection in breast and
colorectal cancers :
HPV in Breast and Colorectal Cancers
Work on HPV in BC and CR in KSA is in progress….

21. In KSA:
1. 83% of cervical cancers in our patients are
associated with HPV infection.
2. 15 different HPV genotypes (6, 16, 18, 31, 33, 39,
45, 51, 52, 56, 59, 64, 70, 73 and 82).
3. The two most common HPV genotypes were 16
and 18 that formed together 80% of HPV
infections and 67% of all cervical cancer patients.
Conclusions
These data provide basic information for decision
makers regarding prevention of cervical cancer in Saudi
Arabia and the implication on screening and
vaccination against HPV infection

22. Implication for screening of cervical cancer
in Saudi Arabia
1. Although cervical cancer is the
3rd most common cancer affecting
women worldwide, its incidence is
low in Saudi women forming
about 2.4% of newly diagnosed
cancer cases.
2. There are no national screening
program for cervical cancer in KSA.
Pap smear is only available for limited number of women
attending routine gynecological examination in major
university-based hospitals

23. Prevention of Cervical Cancer by HPV
Vaccination in Saudi Arabia
1. Since 83% of our patients are HPV positive, vaccination
is expected to protect more than three quarters (3/4) of
cervical cancers in the Kingdom.
2. However, cervical cancer incidence
is very low (2.4%) in Saudi women.
3. Therefore, population-wide vaccination
program would not be cost-effective
and may not sensibly decrease the
incidence of cervical cancer at the
population level.
There are no national vaccination program against HPV in KSA.
HPV vaccines are available in major hospitals for females well
informed about the risk and voluntarily wishes to be vaccinated.
Virus-like
Particles
(VLPs)
Assembled
from the L1
Protein of
Human
Papillomavi
rus 16

24. 14 March 2011Proposal: Vaccination against Human Papilloma Virus
(HPV) to Prevent Cervical Cancer in Saudi Arabia
EXECUTIVE SUMMARY
Prevention of cervical cancer is provided by screening and vaccination against
HPV infection. Recommendations for the use of HPV vaccine are increasing
worldwide. Two available vaccines (Cervarix and Gardasil) against the most
common HPV genotypes (HPV-16 and 18) are being introduced in Western
countries, and promising new broad-spectrum vaccines are in development. The
Center for Disease Control (CDC) in USA advocates using three injections for
optimum protection. Vaccinations are recommended for 11-26 year-old females.
The application of such a vaccination program in Saudi Arabia requires knowledge
about the particularity of this disease in the Kingdom:
1. Eighty-nine percent of uterine cervical tumors in Saudi Arabia are HPV
positive with 79% having high-risk HPV-16/18 infections. Therefore,
vaccination is expected to protect against more than three quarters of
cervical cancers in the Kingdom.
2. Although cervical cancer is the 2nd
most common cancer affecting women
worldwide, its incidence is low in Saudi women forming about 3% of newly
diagnosed cancer cases.
3. Therefore, vaccination program would not be cost-effective and may not
sensibly decrease the incidence of cervical cancer at the population level.
4. However, there may be specific individual benefits from screening or
vaccination for selected women at risk for cervical cancer or women well
informed about the risk and voluntarily wishes to be vaccinated.
5. HPV is also implicated in other anogenital, oro-pharyngeal, colorectal and
breast tumors forming about 25% of all cancer cases. If the vaccine is equally
efficient, reducing the burden of those tumors would justify the implementation
of a cost-effective national vaccination prog
Recommendations and Vaccine Implementation

25. Acknowledgments:
Research Centre:
Najla Al-Harbi, L. Aubrey Venturina, Nikki Venturina, Sara Al-Qahtani, Mr.
Khaled Al-Hadyan, Ms. Muneera Al-Buhairi and Dr. Belal Moftah
Pathology & Laboratory Medicine:
Dr. Asma Tulbah, Ms. Vangie Tanawan, Mr. Tufail Khan
Radiation Oncology Centre:
Drs.: Khalid Balaraj, Medhat El-Sebaie, Raef Ahmed, Rana Mahmood, Ehab
Khalil, Mohamed Aldehaim
Nurses: Ms. Shiny Thayyil, Mini Thayyil, Esperanza Estrada, Liza
Simplicio, Jettimol George, Nehaya Hassan, April Higham
Obstetrics & Gynecology:
Drs. Ismail Albadawi, Hani Salem, Osama Alomar, and Murad Al-Aker
Funding:
King Abdulaziz City for Science and Technology (KACST) grant # 12-
MED2945-20, LGP-12-4 , ARP-27-12, and KFSHRC grants (RAC # 2130 025,
2060-027, 2060-029, 2100-010).

26. THANK YOU
‫ﺷﻛرا‬
The 1st Scientific Meeting of Cancer Care for General Gynecology
Chair Abdullah Basalamah for Gynecological Cancers, Jeddah, 13-14 May 2015

27. • The cervix is part of the female
reproductive tract at the opening
of uterus - vaginal canal.
• There are two cell types:
squamous and glandular.
• Cervical cancers occur in the
transition (transformation) zone
between the two cell types.
• There are 2 main histological
types of cervical cancers:
1. Squamous cell carcinoma 80 – 90%
2. Adenocarcinoma 10% - 20%
• Adenocarcinomas are increasing in the last 3 decades.
Rarely, adenosquamous or mixed carcinomas.
Cancer of the cervix
Transformation
zone

28. CIN 1
(condyloma)
CIN 1 (mild
dysplasia)
CIN 2 (mod.
dysplasia)
Normal
Invasive
cancerCIN 3
(severe dysplasia / CIS)
Pre-cancer: Cervical Intraepithelial Neoplasia (CIN)
Basal cells
Basement
membrane
Histology
of
squamous
cervical
epithelium
Cervical Cancer: What you need to know. http://www.cancer.ca
HPV-mediated progression to cervical cancer:
* HPVs access basal cells through micro-abrasions in cervix epithelium.
* Expression E1,2,4,5,6,7 genes &
episomal viral DNA replication.
* Express L1,2 to encapsidate virions
* Shedded virus initiate new infection.
* Low-grade CIN support replication.
* HR-HPV progress to high-grade CIN.
* In invasive cancer: HPV integrate
to host genome, loss of E2,
upregulation of E6,7 oncogene.

29. HPVs & host genetic predisposition:
• TP53 gene contains a common polymorphism that is a G-to-C
transversion at codon 72 (rs1042522) located in exon 4.
• This non-synonymous SNP results in Arg to Pro substitution
in the amino acid sequence of the p53 protein.
• Storey et al (1998)
found an association
between the arginine
form of p53 and
cervical cancer
development.
• This had suggested
that the
corresponding G
genotype is more
susceptible to HPV E6
mediated degradation.
Suggested mechanism explaining the susceptibility
of Arg to degradation by viral HPV E6 protein, which
may predispose carriers to cancer.

30. Study aim:
To evaluate HPV infection and genotypes in invasive cervical
cancer in Saudi Arabia
Patients and methods:
• 174 patients with cervical cancer.
• DNA extracted from paraffin-embedded tissues.
• HPV was detected using Linear Array HPV Genotyping Kit
(Roche) that enables the
detection of 37 most common
anogenital high (13) & low-risk
(24) genotypes: 6, 11, 16, 18, 26,
31, 33, 35, 39, 40, 42, 45, 51, 52,
53, 54, 55, 56, 58, 59, 61, 62, 64,
66, 67, 68, 69, 70, 71, 72, 73 (MM9),
81, 82 (MM4), 83 (MM7), 84 (MM8), IS39, and CP6108.
• PCR using GP5+/GP6+ common primers for confirmation.
Prevalence & Genotypes’ Distribution of HPV in
Invasive Cervical Cancer in Saudi Arabia