Table 4: Distribution of healthy individuals and cervix cancer patients according to ABO/Rhesus blood group system

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• Distribution of Healthy Individuals and Cervix Cancer Patients According to Rhesus factor:

The distribution of Rh⁺ and Rh^- blood groups showed a significant (P<0.01) difference between healthy individuals and cervix cancer patients that, were 82% & 18%, and 95.3%& 4.7%, among healthy individuals and cervix cancer patients, respectively (Table. 5& Figure. 5).

Table 5: Distribution of healthy individuals and cervix cancer patients according to Rhesus factor

Image is available at PDF format

DISCUSSION:

The results of the current study showed that the mean age of the cervix cancer patients was 53.37±11.6 years (26–88 years). The higher distribution of cervix cancer patients was 42.7% in the age group (45-54) years while the lower distribution of cervix cancer patients was 1.3% in the age group (85-94) years. Similar results were recorded by (El, M. M. et al., 2010) who reported that the median age of incidence of cervix cancer in eastern Libya was 50 years. (Wang, L. et al., 2017) reported that the median age of the cervix cancer patients was 51 years (range, 25- 79 years). Also, (Ahmed, Y. et al., 2017) mention that the majority of the cervical cancer subjects were in the 51-60 years of age group. In addition, (Gascon, P., & Barrett-Lee, P. J. 2006) reported that 70% of cervical cancer in Nigeria was seen between 26-50 years with a peak age range of 34-45 years.

Three variant alleles of the ABO gene on chromosomes 9q34 determine a person's blood type by encoding three glycosyltransferases with different substrate specificities. The ABO blood groups are defined by carbohydrate moieties displayed on the surface of red blood cells and attached to a protein backbone known as the H antigen (Roitt, I. M., & Delves, P. H. 1992). Glycosyltransferases are also important mediators of intercellular adhesion and membrane signaling. They play important roles in malignant progression and spread (Reid, M. E., & Mohandas, N. 2004). These surface molecules have been associated with the host immune response and may have a role in facilitating immunosurveillance for malignant cells (Hakomori, S. I. 1999). Specific red blood cell antigens have been associated with infection, immune response, and disease condition, especially cancers (Saxsena, S., & Gupta, K. 2016).

The distribution of A, B, AB, and O blood groups were showed a significant (P< 0.01) difference between cervix cancer patients and healthy individuals, that were 36.7%, 17.3%, 4.7% & 41.3%, and 24.7%, 16.7%, 11.3%& 47.3%, respectively. These results are run parallel to that recorded by (Kaur, I. et al., 1992) who observed that a strong association between the incident of carcinoma of cervix and blood group A and a weaker association with blood group B. Individuals with blood group O appear to be more resistant to the development of cancers (Gupta, S. et al., 1981). The presence of an A-like antigen (MRG-1) in cervical tissues and persons with blood group A and AB are more susceptible to tumor since they do not have anti-A antibodies which can eliminate tumor cells by killing (Cui, Y. et al., 1993; Vaillant, A. J. et al., 2013). (Freed, D. L. 1999) reported that cancers, in general, tend to be associated with blood group A and slightly less strongly with blood group B. Other studies also suggest that ovarian cancer have also a strong association with blood group A (Metoki, R. et al., 1989). (Saxsena, S., & Gupta, K. 2016) found that blood group A has the highest incidence followed by B, and O among patients with gynecological cancer whereas the blood group AB has the lowest incidence among gynecological cancer patients in a study carried out in Western Rajasthan. Carriers of A and AB blood groups had a significantly increased risk of laryngeal carcinoma (Pyd, M. et al., 1995). The carriage of A and AB groups significantly correlated with an increased risk of gallbladder cancer (Pandey, M. et al., 1995). Also, (Aird, I. et al., 1953) demonstrated that the frequency of blood group A is greater and the frequency of blood group O is less in patients with gastric cancer. The studies of (Flavarjani, A. H. M. et al., 2014; Saxena, S. et al., 2015) were found that a correlation between blood group A and breast cancer. Also, (Stamatakos, M. et al., 2009) reported that blood group A was associated with ductal breast cancer (49.6%), in contrast to the other blood groups and particularly to blood group AB (3.6%). In addition, it has been demonstrated that subjects possessing the blood group O have a lower risk of pancreatic cancer compared to those with groups A or B (Wolpin, B. M. et al., 2010). (Marinaccio, M. et al., 1995) reported that gynecological tumors including, endometrial and cervical cancer are more in women with blood type A, but it is not statistically significant. (Yuzhalin, A. E., & Kutikhin, A. G. 2012) found that a none statistically significant correlation between ABO blood groups and cervical cancer in South East Siberia. But, the predominance of blood group A (36.0%) and group O (36.01%).

Blood group antigens are expressed in many other tissues, including breast lobular cells, ductal cells, and even some malignant cells (Saxsena, S., & Gupta, K. 2016; Yazer, M. H. 2005). The ABO antigen expressed on the surface of malignant cells appears to be different from the antigen expressed on normal tissue (Strauchen, J. A. et al., 1980; Vowden, P. et al., 1986). The different expression of antigens on the surface of cancer cells might alter motility, apoptosis, and immune escape (Le, P. J. et al., 2001) Blood group antigens may influence the systemic inflammatory response which has been associated with the malignancies (Saxsena, S., & Gupta, K. 2016; Melzer, D. et al., 2008; Paterson, A. D. et al., 2009; Barbalic, M. et al., 2010; & Qi, L. 2010). There may be some association between cervical carcinoma and blood group, but there is no clear explanation about its role in pathogenesis. However, it is reported that the ABO-type antigens are expressed at low levels in normal cervical tissue but are expressed at a higher frequency in cervical carcinoma tissues (Tailor, H. J. et al., 2020).

The expression of histo-blood group A antigen has been reported to increase resistance to apoptosis and facilitate escape from immune control in rat colon carcinoma cells (Zhang, S. et al., 1997). Deletion or reduction of histo-blood group A or B antigen in tumors of A or B individuals is correlated with the degree of malignancy and metastatic potential in many types of human cancers (Marionneau, S. et al., 2002). The functional significance of ABO blood group distribution might be associated with biological characteristics such as differentiation, mean size of the tumor, venous invasion, and TNM stages of esophageal squamous cell cancer (Itzkowitz, S. H. 1992). (Schuessler, M. H. et al., 1991) suggested that alterations in glycosyltransferase specificity may occur during pancreatic tumorigenesis. Glycosyltransferase specificity has broad implications, beyond defining ABO blood type. Glycoconjugates are important mediators of intercellular adhesion and membrane signaling, two processes integral to malignant progression and spread (Reid, M. E., & Mohandas, N. 2004). These surface molecules are recognized by the host immune response and may have a role in facilitating immunosurveillance for malignant cells (Hakomori, S. I. 2001; Roseman, S. 2001). Women of blood group A might be at higher risk of cancers involving diminished immunological surveillance. Some tumors, notably of the colon and stomach, express the Forssmann antigen which is structurally similar to the A antigen determinant. People with blood groups other than A produce anti-A antibodies. Because of structural similarity, these antibodies might also attack precancerous or cancerous cells expressing the Forssmann antigen. Thus, some people of blood group A may have a diminished immune response to the tumor (MEHRoTRA, R., & GARG, S. 1998).

In contrast, (Su, M. et al., 2001) reported that the frequency of the blood group B was significantly higher in Chinese patients with cardiac cancer and esophageal carcinoma. (Sharma, G. et al., 2007) reported that the frequency of blood group B (36.11%) and O (35.99%) followed by A (19.44%) but revealed a lack of association between ABO blood groups with cancer of the cervix in 108 cases in Bhopal. Also, (Lee, J. K. et al., 2013) found that a higher significant incidence of carcinoma cervix among blood group B (55%) patients in 100 cases of cervical cancer patients in the semi-urban population in India. In addition, (Akhtar, K. et al., 2010) found that a predominance of blood group B (37.9%) in 406 cancer patients in Northern India.

(Tyagi, S. P. et al., 1967) found that the AB blood group has a higher significant risk compared to the stable blood group O with carcinoma cervix. (Vaillant, A. J. et al., 2013) found that a higher association of carcinoma cervix with blood group O compared to blood groups A, B, or AB among 319 cervix cancer patients. Blood group antigens AB and H expression on cervical cancer cells has been linked with good prognosis and shown to be a predictor of patient survival. The expression of ABH antigens on premalignant and malignant cervical lesions should be investigated as a possible diagnostic and classification tool in cervical neoplasm.

The distribution of patients according to the region were 20.7%, 20%, 19.3%, 13.3%, 8%, 7.3%, 6.7%, and 4.7% in Tripoli, South Libya, Zawia, East Libya, Surman, Aljabl Algarbi, West Sabratha, and Sabratha, respectively.

Similar results were recorded by (Lee, J. K. et al., 2013) who reported that a relatively increased risk of cervical carcinoma for those residing in the rural areas, compared to that of the urban areas. The rural residency was suggested to have low-income, lower education, which in turn leads to low awareness towards hygiene, knowledge of cervical carcinoma, its screening programs, difficulty in persuading women for screening, leading to a delayed diagnosis and increased mortality (Lee, J. K. et al., 2013; Kaku, M. et al., 2008; & Damiani, G. et al., 2012).

ABO blood group phenotype is different among different regions hence distribution among cervical carcinoma is also different for a particular region and also heterogeneity in result largely depends on study design, sample size, races, socioeconomic status, and other associated factors like sexual partners, number of biological fathers, number of children and the use of contraceptive (Vaillant, A. J. et al., 2013).

(Parikh, S. et al., 2003) reported that women in the lower social class were at approximately 80% increased risk of cervical disease than women in the middle social class group that were at 26% as compared to women in the upper social class group. Lifestyle factors are the primary cause of the social class differences which emphasize the future cervical cancer prevention programs to include vaccination and screening especially for women from low socioeconomic groups so that they benefit best.

(Lee, J. K. et al., 2013) observed that women with more children (multipara) have a relatively higher odds ratio than that of unipara, although not statistically significant. The odds ratio showed an alarming increased odds ratio of 4.07 for multipara women. One study showed that women with 3 or more births showed a 1.51 increased odds ratio to carcinoma cervix (Satija, A. 2012). Again, this reinforced the conventional claim that multipara women are more prone to carcinoma cervix.

The distribution of A⁺, A^-, B⁺, B^-, AB⁺, AB^-, O⁺, and O^- blood groups showed a significant (P<0.05) difference between healthy individuals and cervix cancer patients that, were 23.3%, 1.7%, 11.7%, 5%, 6.7%, 5%, 38.3% & 8.3%, and 34.7%, 2%, 14.7%, 2.7%, 4.7%, 0%, 41.3%& 0% among healthy individuals and cervix cancer patients, respectively. Our results are near to the results of the study of (Dixit, R. et al., 2020) who reported that the distribution of A⁺, A^-, B⁺, B^-, AB⁺, O⁺, and O^- blood groups showed a non-significant (P<0.068) difference between healthy individuals and cervix cancer patients that, were 13.9%, 1%, 37.3%, 1.9%, 0%, 39.2% & 1.9%, and 21.4%, 1.1%, 40.1%, 1.6%, 6.4%, 26.7%& 2.7% among healthy individuals and breast cancer patients, respectively. Also, (Kelala, A. A. S. 2020) reported that the distribution of A⁺, A^-, B⁺, B^-, AB⁺, O⁺, and O^- blood groups showed a significant difference between most of breast cancer patients and healthy individuals that, were 57.1%, 2.4%, 4.7%, 1.6%, 1.7%, 31.2%& 2.9%, and 28.82%, 8.24%, 4.11%, 1.9%, 20%, 23.53% & 15.29%, among healthy individuals and breast cancer patients, respectively.

The distribution of Rh⁺ and Rh^- blood groups showed a significant (P<0.01) difference between cervix cancer patients and healthy individuals that, were 95.3%& 4.7%, and 82% & 18%, among healthy individuals and cervix cancer patients, respectively. These results are run parallel with the results of (Meo, S. A. et al., 2017) suggested that the risk of breast cancer is high for the Rh⁺. Also, ((Kelala, A. A. S. 2020) recorded that a significant difference (P<0.01) between the distribution of Rh⁺ and Rh^- blood groups in breast cancer patients (94.7%, 5.3%) and healthy individuals (75.88%, 24.12%), respectively. Many previous studies showed that the breast cancer patients with Rh⁺ were 97.1% (Flavarjani, A. H. M. et al., 2014), 93.4% (Stamatakos, M. et al., 2009; Shiryazdi, S. M. et al., 2015; & Payandeh, M. et al., 2015) 88% (Urun, Y. et al., 2012), and 82% (Cihan, Y. B. 2014). In contrast, (Yuzhalin, A. E., & Kutikhin, A. G. 2012) found that none statistically significant correlations between ABO blood groups and Rhesus factor and cervical cancer in South East Siberia. (Yu, J. et al., 2012) failed to demonstrate an association between ABO blood type and Rh factor. Similarly, (Stamatakos, M. et al., 2009) reported inconsistent results between Rh factor and breast cancer risk.

CONCLUSION:

It can be concluded that the mean age of the cervix cancer patients was 53.37years and the higher distribution of cervix cancer patients was in the age group (45-54) years. The distribution of A, B, AB, and O blood groups were 36.7%, 17.3%, 4.7% & 41.3%, among cervix cancer patients. The distribution of Rh+ and Rh- blood groups were 95.3% & 4.7%, among cervix cancer patients. Further studies are needed to confirm these results.

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