HPV in Cervical & otherCancers 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 GynecologyChair Abdullah Basalamah for Gynecological Cancers, Jeddah, 13-14 May 2015

Overview from 3 published research papers:

More work in progress ….

* 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 infectiousdiseases (Africa 25% - 10% in developed world), second only to tobacco use.

* Certain bacteria and parasitesare 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

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.

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

Cancer group Breast

Anogenital

Colorectal

Head & NeckNone 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

Can

cer

gro

up

• 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 incidencein females:

(females)GLOBOCAN 2008:

Source: http://globocan.iarc.fr

• The most common malignancies in women worldwide:

3rd

• The most common malignancies in human worldwide:

(males+females)

GLOBOCAN 2008:

The global cancer incidence in malesand females:

• Cervical Cancer is the 7th most common cancer in human worldwide.

• It accounts for 4.2% of all cancers.

7th

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

1234567th89101112

131415

Developing countries

12nd3456789101112

131415

GLOBOCAN 2008

Discrepancy between developing & developed countries:

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.

123456789101112th

131415

Most common cancers in Saudi women

GLOBOCAN 2008

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

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

E6APE6p53

p53

Viral Cellular

U UU

Erratic cell

division

U

Degradation

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.

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.

• 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 biphasicoccurrence 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

Num

ber o

f pat

ient

s

0

10

20

30

40

50Adenocarcinoma Squamous cell ca.

HPV in Invasive Cervical Cancer in KSA

Examples of HPV results along with negative and positive controls

HPV Detection and Genotyping

- +16ControlHPV

Genotype: 31181816

5116

391633

52 45 59168259

4564

1670 73

A total of 15 different HPV genotypes, present in single and double infections, were detected in 174 patients.

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-18became 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%

HPV

31: 6

.9%

HPV

45: 5

.5%

HPV1

8: 4

.8%

HPV16

-18: 4

.1%

HPV73: 2.1%

H

PV59: 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%:

• HPV-16/18 were equally frequent in younger (<46) and olderage (≥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

Num

ber o

f pat

ient

s

0

10

20

30

40

50No 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 76-106N

umbe

r of p

atie

nts

0

10

20

30

40HPV6 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

• ~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.

• 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.

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….

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 andvaccination against HPV infection

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

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-effectiveand 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 Papillomavirus 16

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

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, EhabKhalil, Mohamed AldehaimNurses: 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).

THANK YOU

شكرا

The 1st Scientific Meeting of Cancer Care for General GynecologyChair Abdullah Basalamah for Gynecological Cancers, Jeddah, 13-14 May 2015

• 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

Transformationzone

CIN 1(condyloma)

CIN 1 (mild dysplasia)

CIN 2 (mod. dysplasia)

NormalInvasive cancerCIN 3

(severe dysplasia / CIS)

Pre-cancer: Cervical Intraepithelial Neoplasia (CIN)

Basal cellsBasementmembrane

Histology of

squamouscervical

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 integrateto host genome, loss of E2, upregulation of E6,7 oncogene.

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 substitutionin 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 Ggenotype 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.

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