Advanced Stage at Cancer Diagnosis, Higher Mortality in US Patients With HIV

By Marilynn Larkin

May 17, 2019

NEW YORK (Reuters Health) - Cancer patients with HIV in the U.S. are more likely to be diagnosed at advanced disease stages and experience higher cancer-related mortality than cancer patients without HIV, researchers say.

Dr. Meredith Shiels of the National Cancer Institute and colleagues used data from the National Cancer Data Base from 2004-2014 to compare stage of disease at presentation and mortality after diagnosis between more than 14,000 cancer patients with HIV and more than six million HIV-uninfected cancer patients with malignancies of the oral cavity, stomach, colorectum, anus, liver, pancreas, lung, female breast, cervix, prostate, bladder, kidney, thyroid and melanoma.

As reported online May 3 in Cancer, the most common cancer sites in people with HIV were the lung (29.1% of all cases), colorectal (14.1%), and prostate (10.5%); by contrast, the most common sites in those without HIV were the breast (22.8%), prostate (17.8%), and lung (17.7%). This reflects differences in the patient sex distribution by HIV status, according to the authors.

Further, compared with those not infected with HIV, the odds of being diagnosed at an advanced stage of disease were significantly higher in the HIV group for melanoma and cancers of the oral cavity, liver, female breast, prostate, and thyroid (odds ratio for stage IV vs. stage I range, 1.24-2.06).

Mortality was elevated for HIV-infected people with stage I to stage III disease across 13 of the 14 cancer sites evaluated, with hazard ratios ranging from 1.20 for lung cancer to 1.85 for cancers of the female breast to 1.85 for cervix, and 2.93 for thyroid.

Significant differences also were observed in the percentage of uninsured patients with cancer by HIV status (HIV, 5.0% vs. no HIV, 3.3%), with HIV patients being approximately one-half as likely to report private health insurance (HIV, 25.4% vs. no HIV, 44.7%) and approximately three times more likely to be covered by Medicaid (HIV, 17.9% vs. no HIV, 5.9%).

However, Dr. Shiels said, "we showed that these associations are not solely driven by access to health care, as they persisted after adjustment for type of treating health facility and individual health insurance. This provides support for a potential biological link between immunosuppression and cancer progression."

"It is important for clinicians to consider the impact of screening and cancer treatment among HIV-infected people, particularly in the setting of a more aggressive disease course," she stressed. "There is a lack of data on cancer screening among HIV-infected people. For example, we don't really know if women with HIV are receiving adequate cancer screening for breast cancer. This could impact stage at diagnosis and survival."

"In addition, there are data showing that people with HIV are less likely to receive cancer treatment that is standard of care," she said. "Cancer treatment guidelines specifically for people with HIV are warranted to inform treatment decisions."

Dr. Kimlin Tam Ashing, a population sciences professor at City of Hope in Duarte, California, told Reuters Health, "The findings provide clear epidemiological confirmation for what we have concluded from non-comparison studies. This is the first study that I know of to rigorously investigate and document cancer outcomes among cancer patients affected by (HIV) compared to those who are not."

"There were some surprising outcomes, including greater mortality for early-stage cancer and greater mortality for non-infectious or viral cancers," she said by email. "These results show the importance of immune-compromised status and cancer outcomes."

"The most actionable clinical and scientific finding is relevant to the prevalence of lung cancer among (people with HIV)," she noted. These patients, she added, "had lung cancer at almost twice the rate of non-HIV patients...(which) presents an opportunity for both 1) primary prevention intervention, including smoking prevention and cessation and tobacco control among men who have sex with men and/or sexual minority men; and 2) secondary prevention - e.g., lung cancer screening among smokers in this population."

"Another public health and preventive target is prioritizing HPV vaccination among all adolescent and adult (up to age 45) HIV-positive persons," she said, adding that she hopes the authors "will seize the opportunity" to investigate the intersection of race/ethnicity, insurance status and care facility on outcomes, as well as gender/sex and age analyses in future studies.


Cancer 2019.