The United Arab Emirates (UAE) is a confederate of seven emirates situated on the Arabian Gulf peninsula. It is a young country, formed in 1971. Over the last four decades, the UAE has seen a tremendous growth in its infrastructure as a result of its abundant natural resources. Health services in the UAE are provided by the Ministry of Health (MoH), the Abu Dhabi Health Authority and the Dubai Health Authority, through local hospitals and health centres, private hospitals and clinics. Although economic growth has produced a significant improvement in living standards, it has also brought with it many problems. There has been an epidemiological transition in terms of morbidity and mortality; infectious diseases have become phenomena of the past, and chronic diseases have replaced them. According to the MoH,1 cardiovascular disease, accidents and cancer accounted for the majority of deaths in 1998 (responsible for 23.9%, 16.8% and 8.3% of all deaths, respectively). Similar findings were reported by the Abu Dhabi Health Authority in 2009.
According to GLOBOCAN,2 cancers of the breast and cervix are the most common cancers affecting women in the UAE, and a major cause of morbidity and mortality. A lack of awareness of screening programmes among women in Arab societies is a key contributing factor. In the past 10 years, the European Union has begun to focus attention on fighting inequalities in standards of cancer treatment among its member states, using the twin tools of data comparison and programmes aimed at promoting solidarity between countries. In spite of this, the incidence of cervical cancer and its associated mortality rate remain five times higher in certain European countries than in those operating the best screening programmes. In light of this, the MoH in the UAE has drawn up a comprehensive plan3 for the prevention and control of cancer within the country. Its main objective is to reduce both the incidence of cancer and cancer mortality by 60% by the year 2025, with components to include the establishment of national screening programmes for common cancers. A breast screening programme is already established and becoming widely available in Abu Dhabi, with a plan to introduce cervical screening in the future.
Screening is defined as a presumptive identification of unrecognized disease or defect by means of a test, examination, or other procedure that can be applied rapidly.4 The objective of any screening programme is to reduce the risk of death from the disease concerned. The UK National Screening Committee5 has identified a set of criteria that should be fulfilled before a population-based screening programme can be introduced. To ensure the effectiveness of screening, the disease must be (1) prevalent in the population, (2) a major cause of morbidity and mortality and (3) well understood in terms of its epidemiology. Ideally, the disease should have a preclinical phase which can be detected by screening, and an improved survival rate from early diagnosis. In any screening programme, the test must be simple, safe, precise and acceptably easy for physicians and patients. It should be reasonably sensitive and specific and the treatment offered must be effective and evidence based.
It is well established that cancer of the cervix is the second most common cause of death from cancer in women globally.6 It is prevalent in many societies, is a major cause of morbidity and mortality, and the epidemiology and pathogenesis of the disease are well understood. There is a clear preclinical phase detectable by screening, and sufficient evidence in the literature to demonstrate that screening in western countries has resulted in a significant reduction in mortality from cervical cancer.7 The main method used in cervical cancer screening (CCS) is Papanicolaou's stain test, also known as the Pap smear. This method has been practised for more than 50 years without major modification, apart from the introduction of liquid-based cytology. It is safe, simple to use and inexpensive and has been established as the gold standard in the detection and prevention of cervical cancer. Organized screening has reduced mortality rates from cervical cancer by up to 60–70% in western countries.7–10 The Pap test examines a cellular sample, derived from the exfoliated or mechanically dislodged cells of the cervix, vagina and (in some cases) endometrium. These cells are then examined by light microscopy after staining. The major components of the screening programme in cervical cancer comprise a call and recall system (performed by health system management); collection of the smear (in general, the responsibility of the primary health care service); and the processing, reading and reporting of the smear (cytology and pathology).11 The treatment process for women with abnormal smears necessitates a clear management protocol, involving various diagnostic and therapeutic procedures including colposcopy.12 In some cases, alternative surgical-oncological and therapeutic facilities will be required. Auditing and quality control during different stages of the process are fundamental to ensuring high-quality care.5
Knowledge, attitude and practice of cervical cancer screening in the United Arab Emirates
Prior to 1999, well-established facilities for cervical cancer treatment (mainly by radiotherapy) were available in the UAE; however, there were no full-time gynaecological oncologists in the country to deal with the cases surgically and on a regular basis. Until 2003 there were no clear figures showing the prevalence of precancer or cancer of the cervix in the UAE.13–16 The majority of primary health care centres had no facilities for the collection of cervical smears, and physicians' knowledge regarding the screening programme was extremely limited. Cytology services were available, but were not well organized and subject to very little quality control. The same was true of colposcopy services. In 2004, Badrinath et al.13 conducted a study to assess knowledge, attitude and practice of CCS among female primary health care physicians in the UAE, using a self-administered questionnaire. The objectives of the study were (1) to determine the proportion of female primary health care physicians who have performed the Pap smear, and to identify the knowledge and skill areas that need to be addressed if they are to perform routine Pap smears in the future; (2) to elicit physicians' opinions regarding the need for cervical screening in the UAE; and (3) to identify the major reasons for operating any such programme. In spite of its limitations, the study has brought to light many important findings. It emerged that only 40% of female primary health care physicians have ever performed the smear, with many expressing a need for training in procedures such as vaginal examinations, speculum insertion and taking smears. It was clear, therefore, that frontline staff were not yet ready to implement the screening programme. The MoH has been made aware of the results of the study, and has suggested the organization of training programmes for physicians prior to the launch of the CCS programme.
Cervical smear abnormalities in the United Arab Emirates
Subsequently, Ghazal-Aswad et al.15 conducted a pilot study to determine the prevalence of cervical smear abnormalities in the UAE. All female primary health care physicians involved were trained through a combination of lectures and hands-on experience before being allowed to take part in the study. Collection of smears for this study took place over a 2-year period in primary as well as secondary health care facilities. Of the 4500 smears originally estimated, a total of 4055 smears were collected (an 85.5% uptake rate), with nearly 50% obtained from primary and the remainder from secondary health care facilities. An overall 95% satisfactory rate of usable smears was achieved, regardless of where the smears were collected. The cytological results were classified according to the 2001 Bethesda System.11 The overall prevalence of cervical abnormality was 3.6%. Prevalence among women tested at primary health care facilities was double that recorded at secondary care facilities (4.8% as compared with 2.4%; P < 0.01). There were 30 cases of low-grade squamous intraepithelial lesions (SIL) (0.77% prevalence), 21 cases of high-grade lesions (0.53% prevalence) and three cases of glandular cell abnormality (0.077% prevalence). The atypical squamous cells of undetermined significance/SIL ratio was 1.71. No cases of squamous cell carcinoma were detected.
Colposcopy services are essential in the treatment of women with abnormal cervical smears. In the last three decades, colposcopic evaluation of cervical smear abnormalities has been accepted as the norm in the management of these patients. It is important to have a proper referral system, with evidence-based management protocols, to achieve the best results for these women. Ghazal-Aswad et al.16 conducted a cross-sectional questionnaire-based survey to assess the availability of colposcopy services and their quality. This looked at the training received by colposcopists and their particular training needs, as well as the equipment available, procedure performed and audits carried out. Thirty-five of the UAE's government hospitals and four major private hospitals were contacted to determine whether or not they offer colposcopy services. Only 11 government hospitals were found to offer colposcopy, with one planning to introduce the service. All four of the private hospitals provided colposcopy services. Of the 52 specialists performing colposcopy, eight had undergone adequate training (of whom three had been certified) and three had long-term experience in the specialism. The number of cases seen per doctor varied from 10 to 100 per year. Although three hospitals had the basic colposcopy equipment required for diagnosis and treatment, only one unit performed a regular audit. These findings imply that if the government were to introduce a population-based screening programme for cervical cancer, colposcopy services should be centralized within a small number of units. This way, the number of patients seen by each unit should be sufficient to maintain the experience and certification of the colposcopist.
Cervical cancer management
As in other Arab countries, women in the UAE have little or no knowledge about the Pap smear test and, consequently, many have never undergone the test. Interestingly, it has been reported that in countries where awareness is low, patients present with advanced-stage disease. If a nationwide screening programme is to be implemented, it is essential that a major cancer centre be established to deal with all cases diagnosed, as well as any complicated cases of precancer. Tawam Hospital in Al Ain, in affiliation with Johns Hopkins Medicine in Baltimore, MD, USA, is the main tertiary hospital in the UAE and offers most of the facilities necessary for the diagnosis and management of cervical cancer. The gynaecological oncology division, as well as radiotherapy and medical oncology teams, are available to deal with different aspects of the cervical cancer management plan.
Prevention and control in the United Arab Emirates
In collaboration with the International Network on Control of Gynaecological Cancers [World Health Organization (WHO) Collaborating Centre for Research in Human Reproduction and the Gynaecology and Obstetrics department of the University Hospital of Geneva], a National Workshop for Cervical Cancer Prevention and Control was organized in the UAE in 2004, led by the first author of this study and sponsored by the MoH. This was attended by both local and international experts, representing the fields of primary health care, maternal and child health, preventative medicine, obstetrics and gynaecology, pathology, oncology and epidemiology. Experts in public health from WHO were also present. Experts from across the UAE presented their own work and discussed the country's available facilities for CCS. All aspects of the screening programme were discussed thoroughly in small groups, in the presence of the international experts. After 2 days of deliberation on the need for a screening programme in the UAE, the group agreed on the following recommendations:
Initiate an organized screening programme at primary health care facilities, preventative medicine departments and hospitals.
Encourage opportunistic screening. Although the screening programme is population based, the value of opportunistic screening is clear when considered in the context of existing health services; with a majority of women in the UAE experiencing multiple childbirth, opportunistic screening during the antenatal or postnatal period would cover most women.
Pap smears to be enhanced using a liquid-based stain. This is particularly beneficial in the light of a high incidence of inflammatory smears in all populations (S Ghazal-Aswad, unpublished data).
Centralize cytology services and implement stringent quality control, including mechanisms for auditing.
Raise awareness among women through education programmes highlighting the benefits of screening.14
It was recommended that the MoH and Maternal Child Health Departments should launch this programme as soon as possible, under the direction of a committee which would devise, implement, oversee and evaluate the screening programme.
Human papillomavirus vaccine development and its efficacy
Infection with the human papillomavirus (HPV) high-risk group (oncogenic types) – in particular, types 16, 18 and others – is thought to be the most significant risk factor in cervical cancer aetiology, and it is becoming apparent that cervical cancer is caused in large part by HPV.17–19 In June 2006, the Merck Sharp & Dohme quadrivalent vaccine was approved by the Food and Drug Association and made available in different parts of the world. It has the advantage of targeting four HPV types (6, 11, 16 and 18). HPV types 16 and 18 account for around 70–80% of cervical cancers and high-grade precancer lesions, as well as other precancers and cancers of the female lower genital tract. Results from the combined phase II and phase III studies19–21 showed that the efficacy of the quadrivalent HPV vaccine was 100% against high-grade and non-invasive cervical lesions related to HPV types16 and 18. It also reduced the incidence of cervical dysplasia related to HPV types 16 and 18 by 95%. As such, the vaccine has been recommended and implemented in many countries around the world. Recently, the quadrivalent vaccine was introduced by the Preventative Medicine Department in Abu Dhabi, and is now offered to girls at the age of 15 years as a preventative measure against cervical cancer and precancer, as well as other lesions of the lower genital tract.
Risk factors for cervical cancer in Arab populations include HPV infection (mainly types 16 and 18), in addition to early marriages and multiple pregnancies. Screening for cervical cancer by means of the Pap smear is well established as a key intervention for cervical cancer prevention. In many countries where nationwide screening is not yet available, the introduction of the HPV vaccine, and its incorporation into the existing vaccination programme, is another option for policy-makers and professionals in their efforts to protect women against cervical cancer. As the long-term protective effect of the HPV vaccine is still uncertain, it is essential that health policy-makers in the UAE continue to explore the possibility of launching a population-based screening programme for cervical cancer, as recommended at the National Workshop for Cervical Cancer Prevention and Control. Furthermore, effective management of multiple factors, such as individual characteristics and health behaviours of patients, as well as physician providers and clinical systems, will ensure effective population screening. It is anticipated that the experience of the UAE will serve as a learning model for other countries in the Arab world, where CCS and prevention programmes have yet to be initiated.